1619165008 NPI number — DIANE LYNNETTE PERRY NP C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619165008 NPI number — DIANE LYNNETTE PERRY NP C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERRY
Provider First Name:
DIANE
Provider Middle Name:
LYNNETTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOLKA
Provider Other First Name:
DIANE
Provider Other Middle Name:
LYNNETTE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1619165008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 N 3RD ST
Provider Second Line Business Mailing Address:
SUITE 155
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85004-2135
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-496-0721
Provider Business Mailing Address Fax Number:
602-496-0675

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 N 3RD ST
Provider Second Line Business Practice Location Address:
SUITE 155
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85004-2135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-496-0721
Provider Business Practice Location Address Fax Number:
602-496-0675
Provider Enumeration Date:
10/10/2007

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: 363LF0000X , with the licence number:  AP2706 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: AP2709 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: Z125057 . This is a "PTAN MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com