1124151014 NPI number — DR. WANNA PROMMART PSYD

Table of content: DR. WANNA PROMMART PSYD (NPI 1124151014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124151014 NPI number — DR. WANNA PROMMART PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROMMART
Provider First Name:
WANNA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
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:
1124151014
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
491 NAYLOR PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22304-2227
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-722-8872
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 S WHITING ST
Provider Second Line Business Practice Location Address:
SUITE 601
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22304-2227
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-722-8872
Provider Business Practice Location Address Fax Number:
703-212-8407
Provider Enumeration Date:
03/13/2007

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: 103T00000X , with the licence number:  0810003512 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11551672 . This is a "ACQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 199902 . This is a "ANTHEM BLUE CROSS BLUE SH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3403124 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 361274 . This is a "MHN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 027984 . This is a "VMC BEHAVIOR HEALTH SERVI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3769 . This is a "CAREFIRST BLUE CROSS BLUE" identifier . This identifiers is of the category "OTHER".




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