1922398809 NPI number — MISS MICHELLE MARIE DIFFENBAUGH LADC

Table of content: MISS MICHELLE MARIE DIFFENBAUGH LADC (NPI 1922398809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922398809 NPI number — MISS MICHELLE MARIE DIFFENBAUGH LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIFFENBAUGH
Provider First Name:
MICHELLE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LADC
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:
1922398809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1885 UNIVERSITY AVE
Provider Second Line Business Mailing Address:
SUITE 246
Provider Business Mailing Address City Name:
ST. PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-326-7563
Provider Business Mailing Address Fax Number:
651-647-9147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1885 UNIVERSITY AVE
Provider Second Line Business Practice Location Address:
SUITE 246
Provider Business Practice Location Address City Name:
ST. PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55104-3489
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-326-7563
Provider Business Practice Location Address Fax Number:
651-647-9147
Provider Enumeration Date:
04/13/2011

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: 101YA0400X , with the licence number:  302501 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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