1447269428 NPI number — DR. DERENDA JOELLE RICHARDSON N.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447269428 NPI number — DR. DERENDA JOELLE RICHARDSON N.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICHARDSON
Provider First Name:
DERENDA
Provider Middle Name:
JOELLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
N.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIEMER
Provider Other First Name:
DERENDA
Provider Other Middle Name:
DARLENE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MED NCC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1447269428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2025 HUDSON ST
Provider Second Line Business Mailing Address:
UNIT 4
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-261-2732
Provider Business Mailing Address Fax Number:
360-442-4569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2025 HUDSON ST
Provider Second Line Business Practice Location Address:
UNIT 4
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-261-2732
Provider Business Practice Location Address Fax Number:
360-442-4569
Provider Enumeration Date:
08/07/2006

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: 175F00000X , with the licence number:  NT00001372 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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