1467499244 NPI number — MS. PATRICIA DECLUE FNP

Table of content: MS. PATRICIA DECLUE FNP (NPI 1467499244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467499244 NPI number — MS. PATRICIA DECLUE FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DECLUE
Provider First Name:
PATRICIA
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1467499244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
745 BUENA VISTA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANDER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82520-3431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-332-2941
Provider Business Mailing Address Fax Number:
307-332-1920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1460 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANDER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82520-2657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-332-2223
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2006

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: 363LF0000X , with the licence number:  8949.317 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 120173500 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com