1669617338 NPI number — RAELYNN DENISE NUTT DPT

Table of content: RAELYNN DENISE NUTT DPT (NPI 1669617338)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669617338 NPI number — RAELYNN DENISE NUTT DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NUTT
Provider First Name:
RAELYNN
Provider Middle Name:
DENISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SPADY
Provider Other First Name:
RAELYNN
Provider Other Middle Name:
DENISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669617338
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24630 WASHINGTON AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MURRIETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92562-6177
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-696-9353
Provider Business Mailing Address Fax Number:
951-973-7216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31720 TEMECULA PKWY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
TEMECULA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92592-5895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-303-3566
Provider Business Practice Location Address Fax Number:
951-303-3577
Provider Enumeration Date:
12/10/2008

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: 225100000X , with the licence number:  PT 35125 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0PT351250 . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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