1205868809 NPI number — WILLOW MORYAN CNM

Table of content: WILLOW MORYAN CNM (NPI 1205868809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205868809 NPI number — WILLOW MORYAN CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORYAN
Provider First Name:
WILLOW
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
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:
1205868809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 810
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HANOVER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03755-0810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03756-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-650-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/06/2006

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: 367A00000X , with the licence number:  101.0085851 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367A00000X , with the licence number: 046706-23 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30343213 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 373299 . This is a "MVP HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 40Y007826NH01 . This is a "BLUE SHIELD" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 68440 . This is a "BLUE SHIELD" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".
  • Identifier: 1010878 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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