1477729333 NPI number — MRS. JANET CAROL WILLOUGHBY MS OTRL

Table of content: MRS. JANET CAROL WILLOUGHBY MS OTRL (NPI 1477729333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477729333 NPI number — MRS. JANET CAROL WILLOUGHBY MS OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLOUGHBY
Provider First Name:
JANET
Provider Middle Name:
CAROL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOWELL
Provider Other First Name:
JANET
Provider Other Middle Name:
CAROL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS OTRL
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477729333
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
840 PURDY LODGE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89138-6043
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-492-5935
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3030 S JONES BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89146-6792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-360-1137
Provider Business Practice Location Address Fax Number:
702-341-1511
Provider Enumeration Date:
05/01/2008

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: 225XP0200X , with the licence number:  11-0084 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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