1417019936 NPI number — MS. SHIRLEY JANE SAMPLE C.R.N.P.

Table of content: MS. SHIRLEY JANE SAMPLE C.R.N.P. (NPI 1417019936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417019936 NPI number — MS. SHIRLEY JANE SAMPLE C.R.N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMPLE
Provider First Name:
SHIRLEY
Provider Middle Name:
JANE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
C.R.N.P.
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:
1417019936
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11525 HANNIBAL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLEN ARM
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21057-9207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-807-1737
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 BELLONA AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUTHERVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21093-5466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-606-5105
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/14/2006

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: 363LA2200X , with the licence number:  R080367 , 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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