1609271899 NPI number — KAREN WILKES

Table of content: KAREN WILKES (NPI 1609271899)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609271899 NPI number — KAREN WILKES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILKES
Provider First Name:
KAREN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1609271899
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
664 ORANGE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKLEDGE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32955-2413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-208-0245
Provider Business Mailing Address Fax Number:
321-506-0926

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
664 ORANGE COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKLEDGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-208-0245
Provider Business Practice Location Address Fax Number:
321-406-0926
Provider Enumeration Date:
10/30/2014

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: 172V00000X , with the licence number:  6906685 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6906685 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6906685 . This is a "ADULT FAMILY CARE HOME" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 014166300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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