NPI |
1366826836 |
The country code in the location address of the provider being identified. |
Entity Type Code |
1 |
The telephone number associated with the location address of the provider being identified. |
Provider Last Name Legal Name |
KOONTZ |
The date the provider was assigned a unique identifier (assigned an NPI). |
Provider First Name |
BETTIE |
The date that a record was last updated or changed. |
Provider Middle Name |
KATHLEEN |
The code designating the provider’s gender if the provider is a person. |
Provider Name Prefix Text |
MRS. |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider Credential Text |
CAS-I |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider First Line Business Practice Location Address |
17727 E CYPRESS ST |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Provider Business Practice Location Address City Name |
COVINA |
|
Provider Business Practice Location Address State Name |
CA |
The State code in the location of the provider
being identified. |
Provider Business Practice Location Address Postal Code |
917222634 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
Provider Business Practice Location Address Telephone Number |
6269672677 |
The telephone number associated with the location address of the provider being identified. |
Provider Enumeration Date |
7/15/2015 |
The date the provider was assigned a unique identifier (assigned an NPI). |
Last Update Date |
12/13/2016 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider Gender Code |
F |
The code designating the provider’s gender if the provider is a person. |
Healthcare Provider Taxonomy Code 1 |
101YA0400X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider License Number 1 |
4986-I |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider License Number State Code 1 |
CA |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
Is Sole Proprietor |
N |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |