1154772184 NPI number — KAYLA MARIE FRUETEL M.A.

Table of content: KAYLA MARIE FRUETEL M.A. (NPI 1154772184)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154772184 NPI number — KAYLA MARIE FRUETEL M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRUETEL
Provider First Name:
KAYLA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A.
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:
1154772184
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 BARNES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA JUNTA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81050-2138
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-384-5446
Provider Business Mailing Address Fax Number:
719-384-5672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 BARNES AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA JUNTA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81050-2138
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-384-5446
Provider Business Practice Location Address Fax Number:
719-384-5672
Provider Enumeration Date:
06/30/2016

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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