1376695023 NPI number — MARILYN FENTON MONTVILLE

Table of content: MARILYN FENTON MONTVILLE (NPI 1376695023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376695023 NPI number — MARILYN FENTON MONTVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MONTVILLE
Provider First Name:
MARILYN
Provider Middle Name:
FENTON
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:
FENTON
Provider Other First Name:
MARILYN
Provider Other Middle Name:
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:
1376695023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1514 SHEPARD PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CODY
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82414-4220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-587-9596
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
721 SHERIDAN AVE
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
CODY
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82414-3423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-527-5312
Provider Business Practice Location Address Fax Number:
307-578-2212
Provider Enumeration Date:
01/16/2007

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: 101YM0800X , with the licence number:  237 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11661674 . This is a "CAQH UNIVERSAL CREDENTIAL" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".




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