1689914996 NPI number — INDIVIDUALS FIRST CARE COORDINATION

Table of content: LYNNON LEANA CONNERLY CRNA (NPI 1003885294)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689914996 NPI number — INDIVIDUALS FIRST CARE COORDINATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIVIDUALS FIRST CARE COORDINATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1689914996
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3545
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALMER
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99645-3545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-982-9343
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2041 N BROADWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALMER
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99645-9314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-982-9343
Provider Business Practice Location Address Fax Number:
907-746-8620
Provider Enumeration Date:
02/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SKUBE
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR/CARE COORDINATOR
Authorized Official Telephone Number:
907-982-9343

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  980370 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CMX . This is a "SDS PROVIDER NUMBER" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".
  • Identifier: COS 68 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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