1821379397 NPI number — MRS. DONNA MARIE KELLER OSSIPOV LPN

Table of content: MRS. DONNA MARIE KELLER OSSIPOV LPN (NPI 1821379397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821379397 NPI number — MRS. DONNA MARIE KELLER OSSIPOV LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLER OSSIPOV
Provider First Name:
DONNA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELLER OSSIPOV
Provider Other First Name:
DONNA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPN
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1821379397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7058 W PEBBLE VALLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85757-8745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-271-4685
Provider Business Mailing Address Fax Number:
520-297-1956

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7058 W PEBBLE VALLEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85757-8745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-271-4685
Provider Business Practice Location Address Fax Number:
520-297-1956
Provider Enumeration Date:
08/29/2011

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: 164W00000X , with the licence number:  LP033661 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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