1497972343 NPI number — AMY M. KLINE PTA

Table of content: (NPI 1538044714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497972343 NPI number — AMY M. KLINE PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLINE
Provider First Name:
AMY
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FAIRFIELD
Provider Other First Name:
AMY
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PTA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497972343
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4000 N. PROVIDENCE AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APPLETON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54913-8018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-257-2000
Provider Business Mailing Address Fax Number:
920-257-2004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9675 E ELM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POPLAR
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54864-9102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-364-8565
Provider Business Practice Location Address Fax Number:
715-364-8574
Provider Enumeration Date:
04/20/2007

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: 225200000X , with the licence number:  1124-019 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 36138200 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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