1174703466 NPI number — MRS. JODY LYNN DRANGE RD, CDE, ACSM EP-C

Table of content: MRS. JODY LYNN DRANGE RD, CDE, ACSM EP-C (NPI 1174703466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174703466 NPI number — MRS. JODY LYNN DRANGE RD, CDE, ACSM EP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRANGE
Provider First Name:
JODY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, CDE, ACSM EP-C
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:
1174703466
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1474 ETHAN ALLEN HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05445-9569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-881-2936
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
459 N GILBERT RD STE C110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85234-4755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-393-3021
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/05/2007

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: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 305089 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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