1063751576 NPI number — MS. GRETTA HALL BLYTHE RN, IBCLC

Table of content: MS. GRETTA HALL BLYTHE RN, IBCLC (NPI 1063751576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063751576 NPI number — MS. GRETTA HALL BLYTHE RN, IBCLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLYTHE
Provider First Name:
GRETTA
Provider Middle Name:
HALL
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RN, IBCLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HALL
Provider Other First Name:
GRETTA
Provider Other Middle Name:
JANE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063751576
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5127 BOULWARE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28277-9643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-578-6323
Provider Business Mailing Address Fax Number:
704-846-3421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5127 BOULWARE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28277-9643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-578-6323
Provider Business Practice Location Address Fax Number:
704-846-3421
Provider Enumeration Date:
02/04/2013

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: 163WL0100X , with the licence number:  70351 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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