1205093911 NPI number — ANNIE FREDERICK RDT

Table of content: ANNIE FREDERICK RDT (NPI 1205093911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205093911 NPI number — ANNIE FREDERICK RDT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREDERICK
Provider First Name:
ANNIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RDT
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:
1205093911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1576
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWPORT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99156-1576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-921-6560
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11703 E SPRAGUE AVE STE C3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE VALLEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99206-6129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-921-6560
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/20/2008

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 , with the licence number:  DI00000556 , 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: 00719636 . This is a "ADA NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: DI00000556 . This is a "WA CERTIFICATION NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8260051 . This is a "PROVIDER NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 9051731 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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