1073707980 NPI number — JESSICA M S VITTENGL ARNP

Table of content: JESSICA M S VITTENGL ARNP (NPI 1073707980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073707980 NPI number — JESSICA M S VITTENGL ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VITTENGL
Provider First Name:
JESSICA
Provider Middle Name:
M S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SAUCIER
Provider Other First Name:
JESSICA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073707980
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5096
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98227-5096
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-734-2700
Provider Business Mailing Address Fax Number:
360-734-8362

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2979 SQUALICUM PKWY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
BELLINGHAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98225-1811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-734-2700
Provider Business Practice Location Address Fax Number:
360-734-8362
Provider Enumeration Date:
09/04/2007

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: 363L00000X , with the licence number:  AP30007851 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LA2100X , with the licence number: AP30007851 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1073707980 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0280023 . This is a "L&I AND CRIME VICTIMS" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: AF03 . This is a "TRI WEST (TRICARE)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9654005 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0164VI . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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