1518252410 NPI number — MRS. JESECA MARTEL KILLEEN R.PH.

Table of content: MRS. JESECA MARTEL KILLEEN R.PH. (NPI 1518252410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518252410 NPI number — MRS. JESECA MARTEL KILLEEN R.PH.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILLEEN
Provider First Name:
JESECA
Provider Middle Name:
MARTEL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
R.PH.
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:
1518252410
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 E 86TH ST
Provider Second Line Business Mailing Address:
T-1848 STE. 35
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46240-1997
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-461-2604
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 E 86TH ST
Provider Second Line Business Practice Location Address:
T-1848 STE. 35
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46240-1997
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-810-0045
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/20/2011

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: 183500000X , with the licence number:  26023479A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 183500000X , with the licence number: PH25383 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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