1699802553 NPI number — SHAWNA ELISA BENNER-ERICKSON MPT

Table of content: SHAWNA ELISA BENNER-ERICKSON MPT (NPI 1699802553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699802553 NPI number — SHAWNA ELISA BENNER-ERICKSON MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BENNER-ERICKSON
Provider First Name:
SHAWNA
Provider Middle Name:
ELISA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
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:
1699802553
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 HIGHWAY 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDPOINT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83864-1702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-263-1632
Provider Business Mailing Address Fax Number:
208-255-2066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 HIGHWAY 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-1632
Provider Business Practice Location Address Fax Number:
208-255-2066
Provider Enumeration Date:
02/27/2007

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: 225100000X , with the licence number:  PT 1783 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000010152747 . This is a "BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: TD256 . This is a "BLUECROSS# IN GROUP 8M558" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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