1972791556 NPI number — CARLY BRIANN SAMPSON LMT

Table of content: CARLY BRIANN SAMPSON LMT (NPI 1972791556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972791556 NPI number — CARLY BRIANN SAMPSON LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAMPSON
Provider First Name:
CARLY
Provider Middle Name:
BRIANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PUNZALAN
Provider Other First Name:
CARLY
Provider Other Middle Name:
BRIANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972791556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1102 W HAYDEN AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
HAYDEN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-620-7150
Provider Business Mailing Address Fax Number:
208-620-7120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1102 W HAYDEN AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
HAYDEN
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-620-7150
Provider Business Practice Location Address Fax Number:
208-620-7120
Provider Enumeration Date:
10/09/2007

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: 225700000X , with the licence number:  MA00024004 , 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: MAS4614 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0222574 . This is a "WA DEPT.LABOR&INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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