1174852313 NPI number — MISS HATTIE DENISE AVERY

Table of content: MISS HATTIE DENISE AVERY (NPI 1174852313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174852313 NPI number — MISS HATTIE DENISE AVERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AVERY
Provider First Name:
HATTIE
Provider Middle Name:
DENISE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ONUMONU
Provider Other First Name:
DENISE
Provider Other Middle Name:
AVERY
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174852313
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
834 GINGER CT B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT GORDON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-814-8509
Provider Business Mailing Address Fax Number:
706-910-0422

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
834 GINGER CT APT B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT GORDON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30905-4095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-814-8509
Provider Business Practice Location Address Fax Number:
706-910-0422
Provider Enumeration Date:
12/17/2009

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: 246YC3302X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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