1467578799 NPI number — DR. JODY ANN COUSINS MD

Table of content: SABRINA VILLANUEVA GARDNER (NPI 1912469826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467578799 NPI number — DR. JODY ANN COUSINS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COUSINS
Provider First Name:
JODY
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1467578799
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6020 RICHMOND HWY
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22303-2157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-393-3653
Provider Business Mailing Address Fax Number:
877-991-8997

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1213 24TH STREET
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
ANACORTES
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98221-2559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-293-4655
Provider Business Practice Location Address Fax Number:
360-588-1041
Provider Enumeration Date:
03/21/2007

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: 207Q00000X , with the licence number:  7939A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD046860 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 57012332 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: D0086550 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: MD60132209 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2007259 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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