1366682585 NPI number — ELIZABETH SUZANNE SAMPLE PT

Table of content: ELIZABETH SUZANNE SAMPLE PT (NPI 1366682585)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366682585 NPI number — ELIZABETH SUZANNE SAMPLE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMPLE
Provider First Name:
ELIZABETH
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1366682585
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2001 MALLORY LN
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
FRANKLIN
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37067-8233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-373-1350
Provider Business Mailing Address Fax Number:
615-373-7116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
344 HENSLEE DR
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
DICKSON
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37055-2051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-446-7623
Provider Business Practice Location Address Fax Number:
615-446-7624
Provider Enumeration Date:
02/27/2009

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: 225100000X , with the licence number:  8290 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8290 . This is a "TN STATE LICENSE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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