1871684688 NPI number — MS. DIANNE GEE SHUTTLESWORTH LCDCS

Table of content: MS. DIANNE GEE SHUTTLESWORTH LCDCS (NPI 1871684688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871684688 NPI number — MS. DIANNE GEE SHUTTLESWORTH LCDCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHUTTLESWORTH
Provider First Name:
DIANNE
Provider Middle Name:
GEE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCDCS
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:
1871684688
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
166 PAWTUCKET AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAWTUCKET
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02860-3811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-683-3765
Provider Business Mailing Address Fax Number:
401-722-4867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
166 PAWTUCKET AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAWTUCKET
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02860-3811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-722-4644
Provider Business Practice Location Address Fax Number:
401-722-4867
Provider Enumeration Date:
09/27/2006

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: 101YA0400X , with the licence number:  LCDCS00020 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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