1396083101 NPI number — MRS. VICTORIA LYNN CHITTENDEN CO60298403

Table of content: MRS. VICTORIA LYNN CHITTENDEN CO60298403 (NPI 1396083101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396083101 NPI number — MRS. VICTORIA LYNN CHITTENDEN CO60298403

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHITTENDEN
Provider First Name:
VICTORIA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CO60298403
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CALHOUN
Provider Other First Name:
VICTORIA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1396083101
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
945 FAWCETT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-284-7880
Provider Business Mailing Address Fax Number:
253-590-0211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
721 FAWCETT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-473-7586
Provider Business Practice Location Address Fax Number:
253-590-0211
Provider Enumeration Date:
01/29/2013

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: 101YA0400X , with the licence number:  CO60298403 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • 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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