1093802837 NPI number — MRS. KATIE PROWELL ANGUISH DPT

Table of content: MRS. KATIE PROWELL ANGUISH DPT (NPI 1093802837)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093802837 NPI number — MRS. KATIE PROWELL ANGUISH DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANGUISH
Provider First Name:
KATIE
Provider Middle Name:
PROWELL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PROWELL
Provider Other First Name:
KATIE
Provider Other Middle Name:
SUE
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:
1093802837
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:
1010 EAST BUTTERNUT COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28409-4870
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-274-5221
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1140 SHIPYARD BOULEVARD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-799-4199
Provider Business Practice Location Address Fax Number:
910-799-1616
Provider Enumeration Date:
10/05/2006

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: 225100000X , with the licence number:  10514 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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