1487143798 NPI number — JUSTINE CLARISSA CARLISLE CERTIFIED HAIR LOSS

Table of content: JUSTINE CLARISSA CARLISLE CERTIFIED HAIR LOSS (NPI 1487143798)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487143798 NPI number — JUSTINE CLARISSA CARLISLE CERTIFIED HAIR LOSS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLISLE
Provider First Name:
JUSTINE
Provider Middle Name:
CLARISSA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CERTIFIED HAIR LOSS
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:
1487143798
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
504 FORREST CIR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTSVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35811-1938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-261-4066
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3322 MEMORIAL PKWY SW STE 524
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTSVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35801-5367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-261-4066
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2018

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: 1744P3200X , 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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