1417089772 NPI number — MARLYN Y PETERS BSN

Table of content: MARLYN Y PETERS BSN (NPI 1417089772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417089772 NPI number — MARLYN Y PETERS BSN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERS
Provider First Name:
MARLYN
Provider Middle Name:
Y
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BSN
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:
1417089772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2525 HOLLY HALL ST
Provider Second Line Business Mailing Address:
ROOM 200
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77054-4124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-566-6711
Provider Business Mailing Address Fax Number:
713-440-1200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1504 TAUB LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77030-1608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-566-6711
Provider Business Practice Location Address Fax Number:
713-440-1200
Provider Enumeration Date:
03/12/2007

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: 363LW0102X , with the licence number:  523891 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1537334-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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