1154537033 NPI number — DR. NANCY PENROD MONNIE DPT

Table of content: DR. NANCY PENROD MONNIE DPT (NPI 1154537033)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154537033 NPI number — DR. NANCY PENROD MONNIE DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONNIE
Provider First Name:
NANCY
Provider Middle Name:
PENROD
Provider Name Prefix Text:
DR.
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:
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:
1154537033
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1711 SE 26TH CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRESHAM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97080-5291
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-667-5880
Provider Business Mailing Address Fax Number:
503-669-6555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16621 CHAMPION WAY
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SANDY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97055-7257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-668-5321
Provider Business Practice Location Address Fax Number:
503-668-9742
Provider Enumeration Date:
05/15/2007

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: 225100000X , with the licence number:  1094 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0308 . This is a "QUAL-MED" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 071787 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: C884 X 0 . This is a "PACC" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 86971 . This is a "KAISER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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