1396099420 NPI number — DR. NICHOLE LUNDY D.P.T

Table of content: DR. NICHOLE LUNDY D.P.T (NPI 1396099420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396099420 NPI number — DR. NICHOLE LUNDY D.P.T

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNDY
Provider First Name:
NICHOLE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.T
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:
1396099420
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 558
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEWITT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48820-0558
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:
830 W LAKE LANSING RD
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48823-6371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-333-8533
Provider Business Practice Location Address Fax Number:
517-333-8539
Provider Enumeration Date:
10/26/2012

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: 225100000X , with the licence number:  5501014649 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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