1265687529 NPI number — MRS. ERICA LENN SEAGRAVE CNIM

Table of content: MRS. ERICA LENN SEAGRAVE CNIM (NPI 1265687529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265687529 NPI number — MRS. ERICA LENN SEAGRAVE CNIM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SEAGRAVE
Provider First Name:
ERICA
Provider Middle Name:
LENN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNIM
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:
1265687529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
09/26/2018
NPI Reactivation Date:
04/14/2022

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4450
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46082-4450
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-694-1753
Provider Business Mailing Address Fax Number:
317-571-1591

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4851 DEER RIDGE DR S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARMEL
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46033-8910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-694-1753
Provider Business Practice Location Address Fax Number:
317-571-1591
Provider Enumeration Date:
11/28/2008

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: 2472E0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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