1316587249 NPI number — PAULETTE MADELINE VENZEN-POTTER

Table of content: PAULETTE MADELINE VENZEN-POTTER (NPI 1316587249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316587249 NPI number — PAULETTE MADELINE VENZEN-POTTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VENZEN-POTTER
Provider First Name:
PAULETTE
Provider Middle Name:
MADELINE
Provider Name Prefix Text:
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:
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:
1316587249
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7630 ESTATE TUTU VLY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST THOMAS
Provider Business Mailing Address State Name:
VI
Provider Business Mailing Address Postal Code:
00802-1744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
340-998-1858
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1619 SIXTH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST THOMAS
Provider Business Practice Location Address State Name:
VI
Provider Business Practice Location Address Postal Code:
00802-2635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
340-777-7900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2020

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: 104100000X , with the licence number:  1-23450-1B , registered in the state of VI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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