1366578528 NPI number — MS. LADANE JERNELL MOSELY MS OTRL

Table of content: MS. LADANE JERNELL MOSELY MS OTRL (NPI 1366578528)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366578528 NPI number — MS. LADANE JERNELL MOSELY MS OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOSELY
Provider First Name:
LADANE
Provider Middle Name:
JERNELL
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS OTRL
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:
1366578528
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:
5505 HIGHGATE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21215-4715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-520-2273
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 CHARLEVOIX DR SE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49546-7085
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-684-8049
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/24/2007

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: 225X00000X , with the licence number:  05398 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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