1306437421 NPI number — MS. ELISABETH THOMPSON PROVENZANO RPH

Table of content: MS. ELISABETH THOMPSON PROVENZANO RPH (NPI 1306437421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306437421 NPI number — MS. ELISABETH THOMPSON PROVENZANO RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROVENZANO
Provider First Name:
ELISABETH
Provider Middle Name:
THOMPSON
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMPSON
Provider Other First Name:
ELISABETH
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RPH
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306437421
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 W RESERVOIR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODSTOCK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22664-1001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-459-8311
Provider Business Mailing Address Fax Number:
540-459-4651

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 W RESERVOIR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22664-1001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-459-8311
Provider Business Practice Location Address Fax Number:
540-459-4651
Provider Enumeration Date:
02/01/2021

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: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com