1457524027 NPI number — RAVEN JACINDA WALL CADC UNDER SUPERVISI

Table of content: RAVEN JACINDA WALL CADC UNDER SUPERVISI (NPI 1457524027)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457524027 NPI number — RAVEN JACINDA WALL CADC UNDER SUPERVISI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALL
Provider First Name:
RAVEN
Provider Middle Name:
JACINDA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CADC UNDER SUPERVISI
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:
1457524027
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2920 CHAUTAUQUA AVE APT 38
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORMAN
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73072-7736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-528-8686
Provider Business Mailing Address Fax Number:
405-528-8692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2920 CHAUTAUQUA AVE APT 38
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORMAN
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73072-7736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-528-8686
Provider Business Practice Location Address Fax Number:
405-528-8692
Provider Enumeration Date:
04/03/2008

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: 101YA0400X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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