1679361364 NPI number — KATELYN KATZAKIAN-MCCORNACK MASSAGE THERAPIST

Table of content: KATELYN KATZAKIAN-MCCORNACK MASSAGE THERAPIST (NPI 1679361364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679361364 NPI number — KATELYN KATZAKIAN-MCCORNACK MASSAGE THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KATZAKIAN-MCCORNACK
Provider First Name:
KATELYN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MASSAGE THERAPIST
Provider Gender Code:
X

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:
1679361364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1799
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENDOCINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95460-1799
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-832-2929
Provider Business Mailing Address Fax Number:
707-968-4779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 E ST
Provider Second Line Business Practice Location Address:
SUITE 205 & 210
Provider Business Practice Location Address City Name:
EUREKA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-832-2929
Provider Business Practice Location Address Fax Number:
707-968-4779
Provider Enumeration Date:
04/30/2025

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: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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