1649215070 NPI number — VICKIE K WEATHERS CNS

Table of content: VICKIE K WEATHERS CNS (NPI 1649215070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649215070 NPI number — VICKIE K WEATHERS CNS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEATHERS
Provider First Name:
VICKIE
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNS
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:
1649215070
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1705 4TH AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINOT
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58703-2912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-839-0474
Provider Business Mailing Address Fax Number:
701-839-0713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 5TH AVE SE
Provider Second Line Business Practice Location Address:
SUITE 502
Provider Business Practice Location Address City Name:
MINOT
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58701-4784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-857-2199
Provider Business Practice Location Address Fax Number:
701-857-2199
Provider Enumeration Date:
06/19/2006

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: 163W00000X , with the licence number:  R28599 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 164X00000X , with the licence number: L9274 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364S00000X , with the licence number: 0388003-02 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 025500 . This is a "BCBS OF ND PIN" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 70009 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00160106 . This is a "RR MEDICARE" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: P00659747 . This is a "RR MEDICARE" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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