1639335102 NPI number — MS. NANCY KITTREDGE STOCKDALE PAC

Table of content: MS. NANCY KITTREDGE STOCKDALE PAC (NPI 1639335102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639335102 NPI number — MS. NANCY KITTREDGE STOCKDALE PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOCKDALE
Provider First Name:
NANCY
Provider Middle Name:
KITTREDGE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
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:
1639335102
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
914 PINEHURST RD SE
Provider Second Line Business Mailing Address:
STE 102
Provider Business Mailing Address City Name:
RIO RANCHO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87124-2219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-896-9412
Provider Business Mailing Address Fax Number:
505-896-9461

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
914 PINEHURST RD SE
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
RIO RANCHO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87124-2219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-896-9412
Provider Business Practice Location Address Fax Number:
505-896-9461
Provider Enumeration Date:
08/04/2008

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: 363A00000X , with the licence number:  PA 2008-0035 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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