1457450181 NPI number — MRS. KRISTIN MALLISSA SAILORS MPT

Table of content: MRS. KRISTIN MALLISSA SAILORS MPT (NPI 1457450181)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457450181 NPI number — MRS. KRISTIN MALLISSA SAILORS MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAILORS
Provider First Name:
KRISTIN
Provider Middle Name:
MALLISSA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HUDSON
Provider Other First Name:
KRISTIN
Provider Other Middle Name:
MALLISSA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457450181
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2516 ROSALIND AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24014-2326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-312-8015
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1995 S MAIN ST
Provider Second Line Business Practice Location Address:
801
Provider Business Practice Location Address City Name:
BLACKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24060-6637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-951-2703
Provider Business Practice Location Address Fax Number:
540-953-0873
Provider Enumeration Date:
09/21/2006

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: 225100000X , with the licence number:  2305204805 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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