1245396720 NPI number — MS. LUCINDA ANN BALLAS ANP

Table of content: MS. LUCINDA ANN BALLAS ANP (NPI 1245396720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245396720 NPI number — MS. LUCINDA ANN BALLAS ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALLAS
Provider First Name:
LUCINDA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ANP
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:
1245396720
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:
770 NE 31ST PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANBY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97013-2104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-651-3322
Provider Business Mailing Address Fax Number:
503-651-3325

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17704 JEAN WAY
Provider Second Line Business Practice Location Address:
105
Provider Business Practice Location Address City Name:
LAKE OSWEGO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97035-5497
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-675-6776
Provider Business Practice Location Address Fax Number:
503-675-2572
Provider Enumeration Date:
12/28/2006

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: 363LA2200X , with the licence number:  079034619N3 ANP-PP , 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)