1073642997 NPI number — MARILYN KLEYN

Table of content: MARILYN KLEYN (NPI 1073642997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073642997 NPI number — MARILYN KLEYN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLEYN
Provider First Name:
MARILYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HAHNEL
Provider Other First Name:
MARILYN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073642997
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9044 SW HARBOR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VASHON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98070-7028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-274-7579
Provider Business Mailing Address Fax Number:
206-463-3089

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17429 VASHON HWY. SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VASHON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98070-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-463-3441
Provider Business Practice Location Address Fax Number:
206-463-3089
Provider Enumeration Date:
03/05/2007

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: 174400000X , with the licence number:  PT00001022 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT00001022 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8340291 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0053521 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: KL3228 . This is a "BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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