1902291768 NPI number — MISS JESSICA LUTHER FNP

Table of content: MISS JESSICA LUTHER FNP (NPI 1902291768)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902291768 NPI number — MISS JESSICA LUTHER FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUTHER
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1902291768
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
723 MEMORIAL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROSSER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99350-1524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-786-2222
Provider Business Mailing Address Fax Number:
509-786-6612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 DALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON CITY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99320-5250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-588-4075
Provider Business Practice Location Address Fax Number:
509-588-4197
Provider Enumeration Date:
03/30/2015

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: 363LF0000X , with the licence number:  AP60545792 , 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: 1902291768 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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