1245303015 NPI number — MRS. ALYSSA LEANNE SUBBERT PT

Table of content: MRS. ALYSSA LEANNE SUBBERT PT (NPI 1245303015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245303015 NPI number — MRS. ALYSSA LEANNE SUBBERT PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUBBERT
Provider First Name:
ALYSSA
Provider Middle Name:
LEANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1245303015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1009 DOLAN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRIMES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50111-1028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
515-778-3926
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 NE DARTMOOR DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUKEE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-987-6267
Provider Business Practice Location Address Fax Number:
515-987-6269
Provider Enumeration Date:
11/17/2006

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: 208100000X , with the licence number:  02888 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: (0) 449579 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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