1649433707 NPI number — KRISTIN LYNN PHELPS PA-C

Table of content: KRISTIN LYNN PHELPS PA-C (NPI 1649433707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649433707 NPI number — KRISTIN LYNN PHELPS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHELPS
Provider First Name:
KRISTIN
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEONARD
Provider Other First Name:
KRISTIN
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649433707
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 4TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRINNELL
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50112-1898
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-236-2055
Provider Business Mailing Address Fax Number:
641-236-2907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRINNELL
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50112-1898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-236-2055
Provider Business Practice Location Address Fax Number:
641-236-2907
Provider Enumeration Date:
07/08/2008

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:  001915 , 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: 73096 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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