1215541636 NPI number — KAITLYN NICOLE PROBELSKI

Table of content: KAITLYN NICOLE PROBELSKI (NPI 1215541636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215541636 NPI number — KAITLYN NICOLE PROBELSKI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROBELSKI
Provider First Name:
KAITLYN
Provider Middle Name:
NICOLE
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:
PROBELSKI
Provider Other First Name:
KAITLYN
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1215541636
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
231 CORNELL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOWELL
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48843-1731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 WILLIAMS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADRIAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49221-2563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-599-5183
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2020

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: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NA . This is a "NA" identifier . This identifiers is of the category "OTHER".




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