1700397452 NPI number — MS. MEAGEN MICHELLE MCKELVEY LMP

Table of content: MS. MEAGEN MICHELLE MCKELVEY LMP (NPI 1700397452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700397452 NPI number — MS. MEAGEN MICHELLE MCKELVEY LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCKELVEY
Provider First Name:
MEAGEN
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MUNROE
Provider Other First Name:
MEAGEN
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700397452
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1129 W MAIN ST STE 172
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98272-2034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-863-0960
Provider Business Mailing Address Fax Number:
425-320-3880

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1129 W MAIN ST STE 172
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98272-2034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-863-0960
Provider Business Practice Location Address Fax Number:
425-320-3880
Provider Enumeration Date:
10/21/2017

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 , with the licence number:  MA00015970 , 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)





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