1912107590 NPI number — MS. SHERICE RENEE MATHERS LMP

Table of content: KRIS ELAINE KENNEDY M.D. (NPI 1225048580)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912107590 NPI number — MS. SHERICE RENEE MATHERS LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHERS
Provider First Name:
SHERICE
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOLDT
Provider Other First Name:
SHERICE
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912107590
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
406 EVANS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98591-9515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-880-1809
Provider Business Mailing Address Fax Number:
360-864-8879

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 LILLY RD NE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98506-5028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-880-1809
Provider Business Practice Location Address Fax Number:
360-864-8879
Provider Enumeration Date:
07/20/2007

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: 174400000X , with the licence number:  MA00023932 , 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: 603272625 . This is a "SHERICE'S MASSAGE" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com