1578923520 NPI number — DOROTHEA BRADY HARRIS CRNP

Table of content: DOROTHEA BRADY HARRIS CRNP (NPI 1578923520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578923520 NPI number — DOROTHEA BRADY HARRIS CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS
Provider First Name:
DOROTHEA
Provider Middle Name:
BRADY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLT
Provider Other First Name:
DOROTHEA
Provider Other Middle Name:
BRADY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578923520
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12101 WOODCREST EXECUTIVE DR STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141-5047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-317-0600
Provider Business Mailing Address Fax Number:
314-317-0606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1720 KNOWLES RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHENIX CITY
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36869-7135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-317-0600
Provider Business Practice Location Address Fax Number:
314-317-0606
Provider Enumeration Date:
03/03/2016

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: 363L00000X , with the licence number:  1-137711 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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