1730819657 NPI number — FAYE MARION WITKOWSKI

Table of content: FAYE MARION WITKOWSKI (NPI 1730819657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730819657 NPI number — FAYE MARION WITKOWSKI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WITKOWSKI
Provider First Name:
FAYE
Provider Middle Name:
MARION
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:
1730819657
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2410 CHAMBERLAIN ST.
Provider Second Line Business Mailing Address:
CLOCKTOWER PLACE, APT #202
Provider Business Mailing Address City Name:
AMES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-507-1044
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
534 WALLACE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50011-4008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-294-8718
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/14/2022

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: 390200000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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