1326546771 NPI number — JAN LEE TRIMBLE KRILEVICH CDPT

Table of content: JAN LEE TRIMBLE KRILEVICH CDPT (NPI 1326546771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326546771 NPI number — JAN LEE TRIMBLE KRILEVICH CDPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRILEVICH
Provider First Name:
JAN LEE
Provider Middle Name:
TRIMBLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CDPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KILLE
Provider Other First Name:
JAN LEE
Provider Other Middle Name:
TRIMBLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CDPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326546771
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6305 189TH PL SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNNWOOD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98036-5134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-599-7740
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2601 SUMMIT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98201-3309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-322-0810
Provider Business Practice Location Address Fax Number:
425-339-2601
Provider Enumeration Date:
01/30/2018

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 , with the licence number:  CO60781160 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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