1699247130 NPI number — TENNILLE ANNA LIGHTFOOT CP00005071

Table of content: TENNILLE ANNA LIGHTFOOT CP00005071 (NPI 1699247130)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699247130 NPI number — TENNILLE ANNA LIGHTFOOT CP00005071

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIGHTFOOT
Provider First Name:
TENNILLE
Provider Middle Name:
ANNA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CP00005071
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHAUSSEE
Provider Other First Name:
TENNILLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699247130
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14025 N KOTH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWMAN LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99025-9484
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-954-7480
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 W GARLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99205-2119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-325-2355
Provider Business Practice Location Address Fax Number:
509-326-3370
Provider Enumeration Date:
12/21/2018

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: 101YA0400X , with the licence number:  CP00005071 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CP00005071 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".