1164791935 NPI number — MRS. RICHELLE JEANNINE DRAKE CLT, MT

Table of content: MRS. RICHELLE JEANNINE DRAKE CLT, MT (NPI 1164791935)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164791935 NPI number — MRS. RICHELLE JEANNINE DRAKE CLT, MT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRAKE
Provider First Name:
RICHELLE
Provider Middle Name:
JEANNINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CLT, MT
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:
1164791935
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15117 HAYNES ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VAN NUYS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91411-1418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-901-6555
Provider Business Mailing Address Fax Number:
818-901-6555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15117 HAYNES ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VAN NUYS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91411-1418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-901-6555
Provider Business Practice Location Address Fax Number:
818-901-6555
Provider Enumeration Date:
12/22/2011

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: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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