1538413109 NPI number — PROVIDENCE HEALTH & SERVICES WASHINGTON

Table of content: DANELLE ALYCE GOLTZ NP (NPI 1265003396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538413109 NPI number — PROVIDENCE HEALTH & SERVICES WASHINGTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE HEALTH & SERVICES WASHINGTON
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROVIDENCE NORTHEAST WASHINGTON MEDICAL GROUP - KETTLE FALLS
Provider Other Organization Name Type Code:
3
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:
1538413109
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 421
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTY LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99019-0421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-685-7848
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 S MEYERS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KETTLE FALLS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99141-7005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-685-7848
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/05/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
ASST SEC ENROLLMNT/DIR REIMB REG
Authorized Official Telephone Number:
425-525-5392

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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