1295045508 NPI number — KELLY EGGLESTON BACHLOR OF ARTS ED.

Table of content: KELLY EGGLESTON BACHLOR OF ARTS ED. (NPI 1295045508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295045508 NPI number — KELLY EGGLESTON BACHLOR OF ARTS ED.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EGGLESTON
Provider First Name:
KELLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
BACHLOR OF ARTS ED.
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:
1295045508
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 56597
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTH POLE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-460-1414
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
764 ADVENTURE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-460-1414
Provider Business Practice Location Address Fax Number:
907-488-2652
Provider Enumeration Date:
10/20/2010

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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