1508934274 NPI number — SHAUNA DENISE BURCHETT OTRL

Table of content: SHAUNA DENISE BURCHETT OTRL (NPI 1508934274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508934274 NPI number — SHAUNA DENISE BURCHETT OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURCHETT
Provider First Name:
SHAUNA
Provider Middle Name:
DENISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTRL
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:
1508934274
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4820 N BEMIS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99205
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:
1605 W GARLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99205-2620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-444-8383
Provider Business Practice Location Address Fax Number:
509-444-8385
Provider Enumeration Date:
12/01/2006

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: 225XN1300X , with the licence number:  OT00002144 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8354177 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6227BU . This is a "ASURIS-REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0158028 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: A002 . This is a "TRICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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