1174681043 NPI number — MRS. KAREN MELIZA WHITTAKER MS

Table of content: MRS. KAREN MELIZA WHITTAKER MS (NPI 1174681043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174681043 NPI number — MRS. KAREN MELIZA WHITTAKER MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITTAKER
Provider First Name:
KAREN
Provider Middle Name:
MELIZA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHITTAKER
Provider Other First Name:
KAREN
Provider Other Middle Name:
ELAINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1174681043
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 12TH AVENUE SO
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
NAMPA
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-463-9450
Provider Business Mailing Address Fax Number:
208-465-9072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17 12TH AVENUE SO
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-463-9450
Provider Business Practice Location Address Fax Number:
208-465-9072
Provider Enumeration Date:
12/04/2006

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: 101Y00000X , with the licence number:  LCPC 301 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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