1124211941 NPI number — MRS. NICOLE J BUURMA DPT

Table of content: MRS. NICOLE J BUURMA DPT (NPI 1124211941)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124211941 NPI number — MRS. NICOLE J BUURMA DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUURMA
Provider First Name:
NICOLE
Provider Middle Name:
J
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VANDERWIELE
Provider Other First Name:
NICOLE
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124211941
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1824 FRONT ST STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNDEN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98264-1729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-354-0585
Provider Business Mailing Address Fax Number:
360-354-1098

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1824 FRONT STREET
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
LYNDEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98264-8708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-354-0585
Provider Business Practice Location Address Fax Number:
360-354-1098
Provider Enumeration Date:
08/24/2007

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: 225100000X , with the licence number:  070015873 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT60011687 , 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)

  • Identifier: CJ4383 . This is a "R.R. MEDICARE GROUP #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: GAB14760 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1619908 . This is a "BCBS IL GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 200852 . This is a "MEDICARE GROUP#" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 568080 . This is a "MEDICARE GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 202542 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 567770 . This is a "MEDICARE GROUP #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1623066 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 367885100 . This is a "US DEPT OF LABOR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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