1417237744 NPI number — MRS. KAREN DIANE ERICKSON-ENSSLIN LMP

Table of content: MRS. KAREN DIANE ERICKSON-ENSSLIN LMP (NPI 1417237744)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417237744 NPI number — MRS. KAREN DIANE ERICKSON-ENSSLIN LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ERICKSON-ENSSLIN
Provider First Name:
KAREN
Provider Middle Name:
DIANE
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:
BRUNSTAD
Provider Other First Name:
KAREN
Provider Other Middle Name:
DIANE
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:
1417237744
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2311 1/2 QUEETS AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOQUIAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-581-7329
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 S. BOONE STREET
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-581-7329
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2011

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:  MA00019289 , 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)





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