1497871180 NPI number — SANPRI Y PURDY-PORTER PT, IBCLC

Table of content: SANPRI Y PURDY-PORTER PT, IBCLC (NPI 1497871180)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497871180 NPI number — SANPRI Y PURDY-PORTER PT, IBCLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PURDY-PORTER
Provider First Name:
SANPRI
Provider Middle Name:
Y
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, IBCLC
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:
1497871180
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10648 PARK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28210-8407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-667-8050
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10648 PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28210-8407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-667-8050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2007

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: 174N00000X , with the licence number:  L-306928 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 10284 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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