1417000340 NPI number — MS. MAUREEN IVERSEN

Table of content: MS. MAUREEN IVERSEN (NPI 1417000340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417000340 NPI number — MS. MAUREEN IVERSEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IVERSEN
Provider First Name:
MAUREEN
Provider Middle Name:
Provider Name Prefix Text:
MS.
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:
1417000340
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:
340 KEYES CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUISUN CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94585-4123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-429-2110
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 E ALASKA AVE
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-644-0485
Provider Business Practice Location Address Fax Number:
650-573-2110
Provider Enumeration Date:
01/22/2007

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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