1497261291 NPI number — JACQUELYN SUZANN DAVIS-DUDKA RN

Table of content: JACQUELYN SUZANN DAVIS-DUDKA RN (NPI 1497261291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497261291 NPI number — JACQUELYN SUZANN DAVIS-DUDKA RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIS-DUDKA
Provider First Name:
JACQUELYN
Provider Middle Name:
SUZANN
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:
1497261291
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1450 LEONARD ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49505-5515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1450 LEONARD ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49505-5515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-774-8789
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2017

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: 163W00000X , with the licence number:  4704239848 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com