1649338047 NPI number — MRS. CHRISTINE HENRIE MERRILL OTR L

Table of content: MRS. CHRISTINE HENRIE MERRILL OTR L (NPI 1649338047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649338047 NPI number — MRS. CHRISTINE HENRIE MERRILL OTR L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MERRILL
Provider First Name:
CHRISTINE
Provider Middle Name:
HENRIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HENRIE
Provider Other First Name:
CHRISTINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649338047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1160 N WOODLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85712-4932
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-419-1059
Provider Business Mailing Address Fax Number:
520-326-0318

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1160 N WOODLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85712-4932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-419-1059
Provider Business Practice Location Address Fax Number:
520-326-0318
Provider Enumeration Date:
12/05/2006

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: 225X00000X , with the licence number:  0006 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 770629 . This is a "AHCCCS MEDICAID" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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