1912873332 NPI number — CALLAHAN TIMOTHY ROSE NODSLE-VICKERS

Table of content: KATELYN ABIVA (NPI 1568271021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912873332 NPI number — CALLAHAN TIMOTHY ROSE NODSLE-VICKERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NODSLE-VICKERS
Provider First Name:
CALLAHAN
Provider Middle Name:
TIMOTHY ROSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1912873332
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12223 MOUNTAIN CRUISER LN NW APT B108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVERDALE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98383-8019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-866-8246
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13765 VINTAGE DR SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98367-7391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-970-2414
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2025

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: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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