1497785778 NPI number — MRS. DELYS V. GRIBBIN PA

Table of content: LAKAYA JOHNSON (NPI 1093573040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497785778 NPI number — MRS. DELYS V. GRIBBIN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIBBIN
Provider First Name:
DELYS
Provider Middle Name:
V.
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RAYSIDE-GRIBBIN
Provider Other First Name:
DELYS
Provider Other Middle Name:
V.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1497785778
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3022 WILLIAMS DR
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
FAIRFAX
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22031-4600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-738-5737
Provider Business Mailing Address Fax Number:
703-573-2959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 E MILLER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DILLEY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78017-3912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-965-1684
Provider Business Practice Location Address Fax Number:
830-965-1278
Provider Enumeration Date:
07/03/2006

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: 363AM0700X , with the licence number:  PA03945 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8N7150 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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