1629271424 NPI number — KRISTAL SHAY DAILEY CNP

Table of content: KRISTAL SHAY DAILEY CNP (NPI 1629271424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629271424 NPI number — KRISTAL SHAY DAILEY CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAILEY
Provider First Name:
KRISTAL
Provider Middle Name:
SHAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MEEKER
Provider Other First Name:
KRISTAL
Provider Other Middle Name:
SHAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629271424
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1735 27TH ST STE B06
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45662-2681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
740-356-8681
Provider Business Mailing Address Fax Number:
740-353-7900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1170 TILE MILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45613-9435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-226-1552
Provider Business Practice Location Address Fax Number:
740-226-6412
Provider Enumeration Date:
06/08/2007

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: 363L00000X , with the licence number:  COA.15146-NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0114609 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100328360 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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