1336737824 NPI number — MARCY KAY ENTZIE II

Table of content: MARCY KAY ENTZIE II (NPI 1336737824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336737824 NPI number — MARCY KAY ENTZIE II

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENTZIE
Provider First Name:
MARCY
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
II
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:
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:
1336737824
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8170 55TH AVE SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEHR
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58460-9160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-378-2268
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8170 55TH AVE SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEHR
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58460-9160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-269-0384
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2021

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: 3747P1801X , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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