1164627220 NPI number — MRS. JENNIFER R PRATT CERT MASTECTOMY FTR

Table of content: MRS. JENNIFER R PRATT CERT MASTECTOMY FTR (NPI 1164627220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164627220 NPI number — MRS. JENNIFER R PRATT CERT MASTECTOMY FTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRATT
Provider First Name:
JENNIFER
Provider Middle Name:
R
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CERT MASTECTOMY FTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REA
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
GENISE
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:
1164627220
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:
2513 IRON FORGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK HILL
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20171-2950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-579-5799
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 S PICKETT ST
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22304-7206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-461-7534
Provider Business Practice Location Address Fax Number:
703-461-7534
Provider Enumeration Date:
06/19/2007

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: 225000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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