1518110089 NPI number — MRS. JACQUI LORRAINE WADE RN., BSN

Table of content: MRS. JACQUI LORRAINE WADE RN., BSN (NPI 1518110089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518110089 NPI number — MRS. JACQUI LORRAINE WADE RN., BSN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WADE
Provider First Name:
JACQUI
Provider Middle Name:
LORRAINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN., BSN
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:
1518110089
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12357 ORCHARD WOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FENTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48430-8434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-629-6626
Provider Business Mailing Address Fax Number:
810-629-6625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12357 ORCHARD WOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FENTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48430-8434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-629-6626
Provider Business Practice Location Address Fax Number:
810-629-6625
Provider Enumeration Date:
10/28/2008

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:  4704224400 , 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)





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