1578096665 NPI number — STACEY COLLEEN WYNNE-URBANOWICZ NP-C

Table of content: STACEY COLLEEN WYNNE-URBANOWICZ NP-C (NPI 1578096665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578096665 NPI number — STACEY COLLEEN WYNNE-URBANOWICZ NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYNNE-URBANOWICZ
Provider First Name:
STACEY
Provider Middle Name:
COLLEEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
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:
1578096665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 S B B KING BLVD # 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38103-2626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-436-1381
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11293 E IDA PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENGLEWOOD
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80111-4102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-406-1164
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2017

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: 363LP2300X , with the licence number:  APN.0993022-NP , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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