1467786178 NPI number — MS. SUSANNE GRACE EDWARDS

Table of content: MS. SUSANNE GRACE EDWARDS (NPI 1467786178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467786178 NPI number — MS. SUSANNE GRACE EDWARDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDWARDS
Provider First Name:
SUSANNE
Provider Middle Name:
GRACE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
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:
1467786178
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18231 SHEPLEY PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHRIDGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91326-3219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-642-2502
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19231 VICTORY BLVD
Provider Second Line Business Practice Location Address:
SUITE 554
Provider Business Practice Location Address City Name:
RESEDA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91335-6308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-776-1755
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2009

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 196856000 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CMM70956F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com