1497880116 NPI number — KELLY KRIETSCH PH.D.

Table of content: KELLY KRIETSCH PH.D. (NPI 1497880116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497880116 NPI number — KELLY KRIETSCH PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KRIETSCH
Provider First Name:
KELLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

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:
1497880116
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1016 W UNIVERSITY AVE
Provider Second Line Business Mailing Address:
SUITE #202
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-2994
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-779-4286
Provider Business Mailing Address Fax Number:
928-774-1148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2935 SOUTHWEST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEDONA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86336-3797
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-203-4844
Provider Business Practice Location Address Fax Number:
928-203-4497
Provider Enumeration Date:
02/22/2007

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: 103TC0700X , with the licence number:  1554 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 12364601 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: AZ0614590 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com