1154464352 NPI number — BESS ELLEN WILFONG OTR, L

Table of content: BESS ELLEN WILFONG OTR, L (NPI 1154464352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154464352 NPI number — BESS ELLEN WILFONG OTR, L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILFONG
Provider First Name:
BESS
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR, L
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:
1154464352
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:
PO BOX 579
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KITTANNING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16201-0579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-543-8614
Provider Business Mailing Address Fax Number:
724-543-8616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 NOLTE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KITTANNING
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16201-7111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-543-8880
Provider Business Practice Location Address Fax Number:
724-543-8788
Provider Enumeration Date:
02/15/2007

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: 225X00000X , with the licence number:  OC008925 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: OC008925 . This is a "PA STATE LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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