1366419749 NPI number — MRS. DIANE COLLEEN AFFHOLTER LMP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366419749 NPI number — MRS. DIANE COLLEEN AFFHOLTER LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AFFHOLTER
Provider First Name:
DIANE
Provider Middle Name:
COLLEEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LUSK
Provider Other First Name:
DIANE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366419749
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:
1260 BLAINE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZILLAH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-781-0549
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 S 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNNYSIDE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98944
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-837-2600
Provider Business Practice Location Address Fax Number:
509-837-2291
Provider Enumeration Date:
03/03/2006

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: 225700000X , with the licence number:  MA00021310 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0201176 . This is a "LTD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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