1700898137 NPI number — TAMARA L WILLITS RPH

Table of content: TAMARA L WILLITS RPH (NPI 1700898137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700898137 NPI number — TAMARA L WILLITS RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLITS
Provider First Name:
TAMARA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPH
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:
1700898137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1049 MOUNDRIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCE
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66049-3724
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-841-2755
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2336 RIDGE CT
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66046-3983
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-841-1950
Provider Business Practice Location Address Fax Number:
785-841-1051
Provider Enumeration Date:
08/13/2006

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: 183500000X , with the licence number:  1-11118 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1-11118 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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