1497416093 NPI number — MRS. JULIE ANN CORPUZ BUCANNON RD, LRD

Table of content: MRS. JULIE ANN CORPUZ BUCANNON RD, LRD (NPI 1497416093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497416093 NPI number — MRS. JULIE ANN CORPUZ BUCANNON RD, LRD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCANNON
Provider First Name:
JULIE ANN
Provider Middle Name:
CORPUZ
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LRD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORPUZ
Provider Other First Name:
JULIE ANN
Provider Other Middle Name:
QUEZON
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RND
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1497416093
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6002
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND FORKS
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58206-6002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 S COLUMBIA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND FORKS
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58201-4044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-780-4045
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/05/2022

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: 133V00000X , with the licence number:  1533 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1533 . This is a "LICENSE REGISTERED DIETITIAN" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".