1396821294 NPI number — MRS. DIANA LYNN BRAY M.S.

Table of content: MRS. DIANA LYNN BRAY M.S. (NPI 1396821294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396821294 NPI number — MRS. DIANA LYNN BRAY M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAY
Provider First Name:
DIANA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DONNELL
Provider Other First Name:
DIANA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1396821294
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:
3410 TEN PIN LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOPLIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64801-8273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-782-5865
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3202 MCINTOSH CIRCLE
Provider Second Line Business Practice Location Address:
STE. LL02
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64801-3646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-347-3508
Provider Business Practice Location Address Fax Number:
417-347-3503
Provider Enumeration Date:
10/31/2006

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:  NBCC CERT. 48566 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YP2500X , with the licence number: 2000158120 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 48566 . This is a "NBCC" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com