1114914454 NPI number — ELIZABETH BLAKE CURTIS

Table of content: ELIZABETH BLAKE CURTIS (NPI 1114914454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114914454 NPI number — ELIZABETH BLAKE CURTIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CURTIS
Provider First Name:
ELIZABETH
Provider Middle Name:
BLAKE
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:
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:
1114914454
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1409 KINGSLEY AVE
Provider Second Line Business Mailing Address:
SUITE 6B
Provider Business Mailing Address City Name:
ORANGE PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32073-4537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-215-2422
Provider Business Mailing Address Fax Number:
904-215-6122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1409 KINGSLEY AVE
Provider Second Line Business Practice Location Address:
SUITE 6B
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32073-4537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-215-2422
Provider Business Practice Location Address Fax Number:
904-215-6122
Provider Enumeration Date:
10/03/2005

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: 225XH1200X , with the licence number:  OT0001647 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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