1164441648 NPI number — ANNE MARIE GRESHAM A.R.N.P.

Table of content: ANNE MARIE GRESHAM A.R.N.P. (NPI 1164441648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164441648 NPI number — ANNE MARIE GRESHAM A.R.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRESHAM
Provider First Name:
ANNE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
A.R.N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NIELSEN
Provider Other First Name:
ANNE
Provider Other Middle Name:
MARIE
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:
1164441648
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 363
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EASTSOUND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98245-0363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-376-6181
Provider Business Mailing Address Fax Number:
360-376-6182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1286 MOUNT BAKER RD
Provider Second Line Business Practice Location Address:
SUITE B208
Provider Business Practice Location Address City Name:
EASTSOUND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98245-8931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-376-6181
Provider Business Practice Location Address Fax Number:
360-376-6182
Provider Enumeration Date:
07/18/2006

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: 163WP0808X , with the licence number:  RN00055071 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0808X , with the licence number: AP30006672 , 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: 0192477 . This is a "LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 41188600498245A002 . This is a "TRICARE (TRIWEST)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 725195 . This is a "GROUP HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 6004GR . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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