1972279875 NPI number — AMY LORAINE KEELER MEDICAL ASSISTANT

Table of content: AMY LORAINE KEELER MEDICAL ASSISTANT (NPI 1972279875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972279875 NPI number — AMY LORAINE KEELER MEDICAL ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEELER
Provider First Name:
AMY
Provider Middle Name:
LORAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MEDICAL ASSISTANT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOCKWOOD
Provider Other First Name:
AMY
Provider Other Middle Name:
LORAINE
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:
1972279875
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 SE PARK CREST AVE APT A7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98683-8371
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-606-4163
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11719 NE 95TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98682-2444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-397-8246
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/19/2021

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 363AM0700X , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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