1619147527 NPI number — CHANDA KAYE WILLSE

Table of content: CHANDA KAYE WILLSE (NPI 1619147527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619147527 NPI number — CHANDA KAYE WILLSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLSE
Provider First Name:
CHANDA
Provider Middle Name:
KAYE
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:
1619147527
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 N 2ND ST APT A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMILTON
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59840-2590
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-201-9213
Provider Business Mailing Address Fax Number:
406-215-9002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 N 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMILTON
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59840-2589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-201-1248
Provider Business Practice Location Address Fax Number:
406-215-9002
Provider Enumeration Date:
03/06/2008

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: 225100000X , with the licence number:  03359 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0665190 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com