1083986251 NPI number — MRS. KATHRYN A. WALL APN

Table of content: MRS. KATHRYN A. WALL APN (NPI 1083986251)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083986251 NPI number — MRS. KATHRYN A. WALL APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALL
Provider First Name:
KATHRYN
Provider Middle Name:
A.
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NEWLAND
Provider Other First Name:
KATHRYN
Provider Other Middle Name:
A.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083986251
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 WESCOTT DR.
Provider Second Line Business Mailing Address:
HBH
Provider Business Mailing Address City Name:
FLEMINGTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-788-6654
Provider Business Mailing Address Fax Number:
908-788-6452

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 RT. 31
Provider Second Line Business Practice Location Address:
STE. 100
Provider Business Practice Location Address City Name:
FLEMINGTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-788-6654
Provider Business Practice Location Address Fax Number:
908-788-6452
Provider Enumeration Date:
02/03/2012

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: 363LP0808X , with the licence number:  26NJ00310900 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 311081 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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