1265738843 NPI number — JEANIE KIM LADD CRNA

Table of content: JEANIE KIM LADD CRNA (NPI 1265738843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265738843 NPI number — JEANIE KIM LADD CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LADD
Provider First Name:
JEANIE
Provider Middle Name:
KIM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1265738843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 37090
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21297-3090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-295-9360
Provider Business Mailing Address Fax Number:
703-295-9369

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4320 SEMINARY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22304-1535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-504-3789
Provider Business Practice Location Address Fax Number:
703-295-9369
Provider Enumeration Date:
01/31/2011

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: 367500000X , with the licence number:  0024169448 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003290300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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