1912159625 NPI number — KRISTY M. MARRIOTT-DUVALL CNP

Table of content: BRIDGETTE LESAR P.T. (NPI 1063445757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912159625 NPI number — KRISTY M. MARRIOTT-DUVALL CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARRIOTT-DUVALL
Provider First Name:
KRISTY
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
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:
1912159625
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1601 BRIGHAM DR
Provider Second Line Business Mailing Address:
SUITE 250
Provider Business Mailing Address City Name:
PERRYSBURG
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43551-7114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-872-7745
Provider Business Mailing Address Fax Number:
419-874-7758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 BRIGHAM DR
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
PERRYSBURG
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43551-7114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-872-7745
Provider Business Practice Location Address Fax Number:
419-874-7758
Provider Enumeration Date:
10/14/2008

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: 163W00000X , with the licence number:  RN-307522 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: NP-10328 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2923948 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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