1124063300 NPI number — SARA WALLENIUS MERTZ A/GNP

Table of content: SARA WALLENIUS MERTZ A/GNP (NPI 1124063300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124063300 NPI number — SARA WALLENIUS MERTZ A/GNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MERTZ
Provider First Name:
SARA
Provider Middle Name:
WALLENIUS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
A/GNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124063300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 BILTMORE AVE STE G276.10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28801-4601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-213-4502
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
286 OVERLOOK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28803-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-213-8442
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  200950150NP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LG0600X , with the licence number: 99007553N4 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 5005118 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 292676 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".