1467990911 NPI number — KATHLEEN HEATHER FITZGERALD DPT

Table of content: KATHLEEN HEATHER FITZGERALD DPT (NPI 1467990911)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467990911 NPI number — KATHLEEN HEATHER FITZGERALD DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
KATHLEEN
Provider Middle Name:
HEATHER
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1467990911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2531 ROCKY RIDGE RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
VESTAVIA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35243-4415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-978-7376
Provider Business Mailing Address Fax Number:
205-978-0861

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
651 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 119
Provider Business Practice Location Address City Name:
GARDENDALE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35071-2789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-608-3113
Provider Business Practice Location Address Fax Number:
205-608-3036
Provider Enumeration Date:
02/05/2017

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:  PTH8305 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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