1861724361 NPI number — MRS. KALI KRYSTEN SPEERSTRA LMP

Table of content: MRS. KALI KRYSTEN SPEERSTRA LMP (NPI 1861724361)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861724361 NPI number — MRS. KALI KRYSTEN SPEERSTRA LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPEERSTRA
Provider First Name:
KALI
Provider Middle Name:
KRYSTEN
Provider Name Prefix Text:
MRS.
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:
WHITE
Provider Other First Name:
KALI
Provider Other Middle Name:
KRYSTEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1861724361
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 131
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOUR LAKES
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-220-4142
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10224 S. ELECTRIC AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOUR LAKES
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-220-4142
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2010

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:  MA 60117477 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X , with the licence number: MA 60117477 , 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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