1699977173 NPI number — KATHRYN DUCKETT IRBY OTR

Table of content: KATHRYN DUCKETT IRBY OTR (NPI 1699977173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699977173 NPI number — KATHRYN DUCKETT IRBY OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IRBY
Provider First Name:
KATHRYN
Provider Middle Name:
DUCKETT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHITE
Provider Other First Name:
KATHRYN
Provider Other Middle Name:
DUCKETT
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699977173
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:
1500 MUSEUM RD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72032-4710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-329-3804
Provider Business Mailing Address Fax Number:
501-329-0718

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 MUSEUM RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72032-4710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-329-3804
Provider Business Practice Location Address Fax Number:
501-329-0718
Provider Enumeration Date:
06/05/2007

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: 225X00000X , with the licence number:  370 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: OTR370 . This is a "LICENCE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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