1467673889 NPI number — JENNIFER A SHAH RN

Table of content: JENNIFER A SHAH RN (NPI 1467673889)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467673889 NPI number — JENNIFER A SHAH RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAH
Provider First Name:
JENNIFER
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN
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:
1467673889
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7340 BRANDTVISTA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45424-3331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-602-1636
Provider Business Mailing Address Fax Number:
937-528-2156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6981 BRECKENWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45424-7326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-602-1636
Provider Business Practice Location Address Fax Number:
937-528-2156
Provider Enumeration Date:
05/02/2007

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: 163WH0200X , with the licence number:  RN-231005 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2644133 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com