1831170158 NPI number — MRS. KAY MICHELLE BROOKS PA C

Table of content: MRS. KAY MICHELLE BROOKS PA C (NPI 1831170158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831170158 NPI number — MRS. KAY MICHELLE BROOKS PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROOKS
Provider First Name:
KAY
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA C
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:
1831170158
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1099
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98356-0018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-496-5145
Provider Business Mailing Address Fax Number:
360-496-5093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4254 JACKSON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEHALIS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98532-8424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-262-3966
Provider Business Practice Location Address Fax Number:
360-262-3967
Provider Enumeration Date:
11/14/2005

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: 363AM0700X , with the licence number:  PA10004588 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: PA0004588 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7132764 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1117829 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7132244 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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