1083702716 NPI number — MS. STEPHANIE LOUISE HERRICK FNP

Table of content: MS. STEPHANIE LOUISE HERRICK FNP (NPI 1083702716)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083702716 NPI number — MS. STEPHANIE LOUISE HERRICK FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERRICK
Provider First Name:
STEPHANIE
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1083702716
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1988 SPRUCE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE HAVASU CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86406-7514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-575-6713
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1987 MCCULLOCH BLVD N
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86403-5682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-453-6963
Provider Business Practice Location Address Fax Number:
928-453-7011
Provider Enumeration Date:
10/10/2006

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: 363LF0000X , with the licence number:  AP328 , 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)

  • Identifier: 144767 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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