1184135477 NPI number — VANESSA IVY MYERS AAS, CRM

Table of content: (NPI 1699293308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184135477 NPI number — VANESSA IVY MYERS AAS, CRM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYERS
Provider First Name:
VANESSA
Provider Middle Name:
IVY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AAS, CRM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MYERS
Provider Other First Name:
IVY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AAS, CRM
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1184135477
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3159 NE 13TH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HILLSBORO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97124-4074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-619-7877
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
152 SE 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HILLSBORO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97123-4293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-202-7881
Provider Business Practice Location Address Fax Number:
503-746-5617
Provider Enumeration Date:
10/13/2017

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175T00000X , with the licence number: 17-CRM-038 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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