1427159664 NPI number — MR. LANNY DOUGLAS APRN

Table of content: MR. LANNY DOUGLAS APRN (NPI 1427159664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427159664 NPI number — MR. LANNY DOUGLAS APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOUGLAS
Provider First Name:
LANNY
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
M

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:
1427159664
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 271144
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT COLLINS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80527-1144
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-556-4502
Provider Business Mailing Address Fax Number:
970-493-5131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 EAST HORSETOOTH RD
Provider Second Line Business Practice Location Address:
SUITE 307
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-556-4502
Provider Business Practice Location Address Fax Number:
970-493-5131
Provider Enumeration Date:
09/26/2006

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: 364SP0807X , with the licence number:  18756.196 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0808X , with the licence number: 180365-5256 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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