1235358003 NPI number — MARY DAHLEN APRN

Table of content: MARY DAHLEN APRN (NPI 1235358003)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235358003 NPI number — MARY DAHLEN APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAHLEN
Provider First Name:
MARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
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:
1235358003
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 DR MICHAEL DEBAKEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CHARLES
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70601-5724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
337-475-8100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 WALTERS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CHARLES
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70607-4647
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-475-8100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2007

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: 363L00000X , with the licence number:  081161 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1022799 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com