1972787976 NPI number — MS. AMY ADELE BAYLIS

Table of content: MS. AMY ADELE BAYLIS (NPI 1972787976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972787976 NPI number — MS. AMY ADELE BAYLIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAYLIS
Provider First Name:
AMY
Provider Middle Name:
ADELE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHAICLIN
Provider Other First Name:
AMY
Provider Other Middle Name:
ADELE
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:
1972787976
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2394
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98632-8455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-200-5419
Provider Business Mailing Address Fax Number:
360-200-6736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1126 S GOLD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTRALIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98531-3768
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-807-4929
Provider Business Practice Location Address Fax Number:
360-807-4160
Provider Enumeration Date:
12/26/2007

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: 101Y00000X , with the licence number:  CG60718696 , 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)

  • Identifier: 2139152 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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