1265766752 NPI number — DARICE DIANE DWYER PHN

Table of content: DARICE DIANE DWYER PHN (NPI 1265766752)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265766752 NPI number — DARICE DIANE DWYER PHN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DWYER
Provider First Name:
DARICE
Provider Middle Name:
DIANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265766752
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
616 AMERICA AVE NW
Provider Second Line Business Mailing Address:
SUITE #130
Provider Business Mailing Address City Name:
BEMIDJI
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56601-3818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-333-8152
Provider Business Mailing Address Fax Number:
218-333-8160

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
616 AMERICA AVE NW
Provider Second Line Business Practice Location Address:
SUITE #130
Provider Business Practice Location Address City Name:
BEMIDJI
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56601-3818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-333-8152
Provider Business Practice Location Address Fax Number:
218-333-8160
Provider Enumeration Date:
09/30/2009

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: 163WC1500X , with the licence number:  R091398-0 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WH0200X , with the licence number: R091398-0 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8231BE . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 567553700 . This is a "PRIME WEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".