1033742291 NPI number — MS. KAITLYN MARIE SHANNON RD, LDN

Table of content: MS. KAITLYN MARIE SHANNON RD, LDN (NPI 1033742291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033742291 NPI number — MS. KAITLYN MARIE SHANNON RD, LDN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHANNON
Provider First Name:
KAITLYN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LDN
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:
1033742291
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20325 NORTH 51ST AVENUE
Provider Second Line Business Mailing Address:
BUILDING 9, SUITE 166
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-341-5248
Provider Business Mailing Address Fax Number:
602-702-5219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20325 NORTH 51ST AVENUE
Provider Second Line Business Practice Location Address:
BUILDING 9, SUITE 166
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-341-5248
Provider Business Practice Location Address Fax Number:
602-702-5219
Provider Enumeration Date:
02/17/2020

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: 133V00000X , with the licence number:  86085245 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com