1174517668 NPI number — MRS. SALLY DALE G JAFARI CRNP

Table of content: MRS. SALLY DALE G JAFARI CRNP (NPI 1174517668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174517668 NPI number — MRS. SALLY DALE G JAFARI CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAFARI
Provider First Name:
SALLY DALE
Provider Middle Name:
G
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REDDISH
Provider Other First Name:
DALE
Provider Other Middle Name:
G
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174517668
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
403 PURDY ST
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
EASTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21601-4059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-822-7040
Provider Business Mailing Address Fax Number:
410-822-7056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 PURDY ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
EASTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21601-4059
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-822-7040
Provider Business Practice Location Address Fax Number:
410-822-7056
Provider Enumeration Date:
09/12/2005

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:  R069947 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 130003200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 287111400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000969542 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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