1669719175 NPI number — RACHEL RENEE WALLACE CRNA

Table of content: RACHEL RENEE WALLACE CRNA (NPI 1669719175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669719175 NPI number — RACHEL RENEE WALLACE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLACE
Provider First Name:
RACHEL
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1669719175
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35505 ROAD K.1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCOS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81328-8978
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1311 N MILDRED RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORTEZ
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-555-6666
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2013

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: 367500000X , with the licence number:  R0088890 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: C-APN.0001428-C-CRNA , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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