1649904939 NPI number — DR. AMANDA NICOLE BASKERVILLE AUD

Table of content: DR. AMANDA NICOLE BASKERVILLE AUD (NPI 1649904939)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649904939 NPI number — DR. AMANDA NICOLE BASKERVILLE AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASKERVILLE
Provider First Name:
AMANDA
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
AUD
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:
1649904939
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
MADIGAN ANNEX, E JOHNSON ST
Provider Second Line Business Mailing Address:
BUILDING 9911C, RAMP 2
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AA
Provider Business Mailing Address Postal Code:
98433
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-968-3431
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MADIGAN ANNEX, E JOHNSON ST
Provider Second Line Business Practice Location Address:
BUILDING 9911C, RAMP 2
Provider Business Practice Location Address City Name:
JOINT BASE LEWIS-MCCHORD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-968-3431
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/12/2022

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: 231H00000X , with the licence number:  LD61318724 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 231H00000X , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237600000X , with the licence number: LD61318724 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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