1518046879 NPI number — KATHRYN ANN LUCAS CNM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518046879 NPI number — KATHRYN ANN LUCAS CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCAS
Provider First Name:
KATHRYN
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LUCAS
Provider Other First Name:
KATHY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNM
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1518046879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2198
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT DEFIANCE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86504-2198
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-729-5231
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
FORT DEFIANCE PHS HOSPITAL
Provider Second Line Business Practice Location Address:
CORNER OF RT N12 AND N7
Provider Business Practice Location Address City Name:
FORT DEFIANCE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-729-8770
Provider Business Practice Location Address Fax Number:
928-729-8804
Provider Enumeration Date:
11/06/2006

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: 367A00000X , with the licence number:  513 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02880580 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 840620 . This is a "AHCCCS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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