1760652515 NPI number — TERRISA R MUSTARD-MARSHALL LMP

Table of content: TERRISA R MUSTARD-MARSHALL LMP (NPI 1760652515)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760652515 NPI number — TERRISA R MUSTARD-MARSHALL LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUSTARD-MARSHALL
Provider First Name:
TERRISA
Provider Middle Name:
R
Provider Name Prefix Text:
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:
1760652515
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10110 19TH AVE SE
Provider Second Line Business Mailing Address:
E-102
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98208-4249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-314-4842
Provider Business Mailing Address Fax Number:
425-339-2221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4323 RUCKER AVE
Provider Second Line Business Practice Location Address:
A
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98203-2213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-314-4842
Provider Business Practice Location Address Fax Number:
425-339-2221
Provider Enumeration Date:
03/07/2008

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: 174400000X , with the licence number:  MA00024827 , 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)





Copyright © 2007-2024 www.npivalidator.com