1568769529 NPI number — HEIDI MICHELLE EHLERT NORDBY L.M.P.

Table of content: HEIDI MICHELLE EHLERT NORDBY L.M.P. (NPI 1568769529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568769529 NPI number — HEIDI MICHELLE EHLERT NORDBY L.M.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EHLERT NORDBY
Provider First Name:
HEIDI
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.M.P.
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:
1568769529
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7313 SE OVERAA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ORCHARD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98367-9728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-621-6488
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 PORT ORCHARD BLVD STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ORCHARD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98366-4705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-895-2224
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/26/2011

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: 225700000X , with the licence number:  MA00013097 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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