1720314149 NPI number — KELLYE M WINBUSH

Table of content: KELLYE M WINBUSH (NPI 1720314149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720314149 NPI number — KELLYE M WINBUSH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WINBUSH
Provider First Name:
KELLYE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1720314149
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1748 E 84TH PL
Provider Second Line Business Mailing Address:
2
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60617-2275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-849-8248
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1748 E 84TH PL
Provider Second Line Business Practice Location Address:
2
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60617-2275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-849-8248
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2009

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: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: HSD0V700 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com