1730395799 NPI number — MRS. KRYSTAL LYNN SHOPE LMP

Table of content: MRS. KRYSTAL LYNN SHOPE LMP (NPI 1730395799)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730395799 NPI number — MRS. KRYSTAL LYNN SHOPE LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOPE
Provider First Name:
KRYSTAL
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
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:
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:
1730395799
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 S CHEHALIS ST
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
ABERDEEN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98520-2957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-537-5914
Provider Business Mailing Address Fax Number:
360-532-1059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 S CHEHALIS ST
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98520-2957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-537-5914
Provider Business Practice Location Address Fax Number:
360-532-1059
Provider Enumeration Date:
05/15/2007

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: 225700000X , with the licence number:  MA00019187 , 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: 602365171 . This is a "UBI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 403369-00 . This is a "NATIONAL CERTIFICATION #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 026245 . This is a "ABERDEEN CITY LICENCE #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: MA00019187 . This is a "STATE LICENCE #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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