1669943395 NPI number — MS. SHIRLENE KELLY SHIRLEY SUDP

Table of content: MS. SHIRLENE KELLY SHIRLEY SUDP (NPI 1669943395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669943395 NPI number — MS. SHIRLENE KELLY SHIRLEY SUDP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIRLEY
Provider First Name:
SHIRLENE
Provider Middle Name:
KELLY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
SUDP
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:
1669943395
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12715 E MISSION AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE VALLEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99216-1027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-323-5766
Provider Business Mailing Address Fax Number:
509-321-5472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3710 N MONROE ST. RIVERSIDE RECOVERY CENTER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-328-5234
Provider Business Practice Location Address Fax Number:
509-328-2358
Provider Enumeration Date:
12/06/2018

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: 101YA0400X , with the licence number:  CP60081248 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2077844 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2118932 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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