1134172034 NPI number — KRISTINE K DOMIER CRNA

Table of content: KRISTINE K DOMIER CRNA (NPI 1134172034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134172034 NPI number — KRISTINE K DOMIER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOMIER
Provider First Name:
KRISTINE
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1134172034
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1027 WASHINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT LAKES
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56501-3409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-847-5611
Provider Business Mailing Address Fax Number:
218-847-0881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1027 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT LAKES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56501-3409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-847-5611
Provider Business Practice Location Address Fax Number:
218-847-0881
Provider Enumeration Date:
05/19/2006

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: 367500000X , with the licence number:  R138036-3 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 041H1DO . This is a "MNBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2003184 . This is a "MEDICA #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 49119 . This is a "AMERICA'S PPO/ARAZ #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1134172034 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 26506 . This is a "NDBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 49119 . This is a "LHS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: HP42498 . This is a "HEALTHPARTNERS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: DA9031016140 . This is a "PREFERRED ONE #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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