1508039041 NPI number — KATHI ELLISON DEBAKER PTA

Table of content: KATHI ELLISON DEBAKER PTA (NPI 1508039041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508039041 NPI number — KATHI ELLISON DEBAKER PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEBAKER
Provider First Name:
KATHI
Provider Middle Name:
ELLISON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PTA
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:
1508039041
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1555 DOUSMAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54303-3207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-494-4525
Provider Business Mailing Address Fax Number:
920-494-6887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1555 DOUSMAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54303-3207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-494-4525
Provider Business Practice Location Address Fax Number:
920-494-6887
Provider Enumeration Date:
04/04/2008

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: 225200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 36137800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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