1861890634 NPI number — KELLIE JO DICKINSON

Table of content: KELLIE JO DICKINSON (NPI 1861890634)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861890634 NPI number — KELLIE JO DICKINSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKINSON
Provider First Name:
KELLIE
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRAHAM
Provider Other First Name:
KELLY
Provider Other Middle Name:
JO
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:
1861890634
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
702 SUNSET DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ONTARIO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97914-3121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-889-9167
Provider Business Mailing Address Fax Number:
541-889-7873

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 SUNSET DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ONTARIO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97914-3121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-889-9167
Provider Business Practice Location Address Fax Number:
541-889-7873
Provider Enumeration Date:
12/10/2014

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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