1790198414 NPI number — MRS. PAMELA CHRISTINE KACZMARCZYK LMP MA 60436997

Table of content: MRS. PAMELA CHRISTINE KACZMARCZYK LMP MA 60436997 (NPI 1790198414)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790198414 NPI number — MRS. PAMELA CHRISTINE KACZMARCZYK LMP MA 60436997

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KACZMARCZYK
Provider First Name:
PAMELA
Provider Middle Name:
CHRISTINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMP MA 60436997
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ERICKSON
Provider Other First Name:
PAMELA
Provider Other Middle Name:
CHRISTINE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790198414
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16088 MCLEAN RD
Provider Second Line Business Mailing Address:
#12
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-840-5899
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 E MONTGOMERY ST.
Provider Second Line Business Practice Location Address:
STE 230
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-840-5899
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/10/2014

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:  MA-60436997 , 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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