1982688263 NPI number — MRS. GAYNELL SUE LADISLAS APN

Table of content: MRS. GAYNELL SUE LADISLAS APN (NPI 1982688263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982688263 NPI number — MRS. GAYNELL SUE LADISLAS APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LADISLAS
Provider First Name:
GAYNELL
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LADISLAS
Provider Other First Name:
GAYNELL
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982688263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 N GARFIELD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OBLONG
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62449-1426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-592-3119
Provider Business Mailing Address Fax Number:
618-592-3875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 N GARFIELD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OBLONG
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62449-1426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-592-3119
Provider Business Practice Location Address Fax Number:
618-592-3875
Provider Enumeration Date:
12/01/2005

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: 363L00000X , with the licence number:  209003339 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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