1043234610 NPI number — KELLY MICHELE CZARNECKI PAC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043234610 NPI number — KELLY MICHELE CZARNECKI PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CZARNECKI
Provider First Name:
KELLY
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FELKINE
Provider Other First Name:
KELLY
Provider Other Middle Name:
MICHELE
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:
1043234610
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1490 N TURQUOISE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-774-5074
Provider Business Mailing Address Fax Number:
928-774-0884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1490 N TURQUOISE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLAGSTAFF
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-774-5074
Provider Business Practice Location Address Fax Number:
928-774-0884
Provider Enumeration Date:
07/27/2006

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 56246 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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