1396598173 NPI number — PEERS ENVISIONING AND ENGAGING IN RECOVERY SERVICES

Table of content: KATIE ELIZABETH WODAEGE CNM, ARNP (NPI 1194498345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396598173 NPI number — PEERS ENVISIONING AND ENGAGING IN RECOVERY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEERS ENVISIONING AND ENGAGING IN RECOVERY SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1396598173
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8393 CAPWELL DR STE 240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKLAND
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94621-2123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-832-7337
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8393 CAPWELL DR STE 240
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKLAND
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94621-2123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-832-7337
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2024

Additional Information

Authorized Official

Authorized Official Last Name:
VANAMAN
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
510-567-7612

Provider Taxonomy Codes

  • Taxonomy code: 175T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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