1316171457 NPI number — MRS. KERRY D PRATER C.O.T.A.

Table of content: AMY KLOBERDANZ CAS, BA (NPI 1821105784)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316171457 NPI number — MRS. KERRY D PRATER C.O.T.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRATER
Provider First Name:
KERRY
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
C.O.T.A.
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:
1316171457
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
726 OAKVIEW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24153-4826
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:
3585 BRAMBLETON AVE
Provider Second Line Business Practice Location Address:
GENESIS REHAB SERVICES AT LOYALTON OF ROANOKE
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24018-6521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-776-1029
Provider Business Practice Location Address Fax Number:
540-776-1038
Provider Enumeration Date:
05/04/2009

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: 224Z00000X , with the licence number:  0131000038 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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