1124177209 NPI number — MRS. NICOLE BRIANNE CHRYST LMP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124177209 NPI number — MRS. NICOLE BRIANNE CHRYST LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHRYST
Provider First Name:
NICOLE
Provider Middle Name:
BRIANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAPRAIM
Provider Other First Name:
NICOLE
Provider Other Middle Name:
BRIANNA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124177209
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5728
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LACEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98509-5728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-539-7726
Provider Business Mailing Address Fax Number:
360-539-7729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1017 4TH AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98506-4016
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-539-7726
Provider Business Practice Location Address Fax Number:
360-539-7729
Provider Enumeration Date:
01/09/2007

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: 174400000X , with the licence number:  MA00022961 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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