1184989634 NPI number — TESSA CAITLIN SKOTNICKI PA

Table of content: TESSA CAITLIN SKOTNICKI PA (NPI 1184989634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184989634 NPI number — TESSA CAITLIN SKOTNICKI PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SKOTNICKI
Provider First Name:
TESSA
Provider Middle Name:
CAITLIN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEITZEL
Provider Other First Name:
TESSA
Provider Other Middle Name:
CAITLIN
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:
1184989634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 SUNNYVIEW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KALISPELL
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59901-3129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-752-7441
Provider Business Mailing Address Fax Number:
406-257-0304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 SUNNYVIEW LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALISPELL
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59901-3129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-752-7441
Provider Business Practice Location Address Fax Number:
406-257-0304
Provider Enumeration Date:
07/11/2012

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: 363A00000X , with the licence number:  574 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA2013-0093 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 57605 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 75658071 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".