1164511341 NPI number — DEBRA BRISTOL APRN

Table of content: DEBRA BRISTOL APRN (NPI 1164511341)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164511341 NPI number — DEBRA BRISTOL APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRISTOL
Provider First Name:
DEBRA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRISTOL
Provider Other First Name:
DEBBIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1164511341
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
976 MOUNTAIN CITY HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89801-2728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-777-7587
Provider Business Mailing Address Fax Number:
775-738-9584

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1250 S CLEARVIEW AVE
Provider Second Line Business Practice Location Address:
100
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85209-3378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-423-4670
Provider Business Practice Location Address Fax Number:
480-654-2922
Provider Enumeration Date:
10/12/2006

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: 363LF0000X , with the licence number:  APN00276 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2407009 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".