Basic Information
| Provider Information | |||||||||
| NPI: | 1326029810 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PLUMMER | ||||||||
| FirstName: | KYLEE | ||||||||
| MiddleName: | VERLEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SUTHERLIN | ||||||||
| OtherFirstName: | KYLEE | ||||||||
| OtherMiddleName: | VERLEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1075 STEVENSON AVE | ||||||||
| Address2: | PATTERSON ARMY HEALTH CLINIC | ||||||||
| City: | FORT MONMOUTH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325320182 | ||||||||
| FaxNumber: | 7325320194 | ||||||||
| Practice Location | |||||||||
| Address1: | 1075 STEVENSON AVE | ||||||||
| Address2: | PATTERSON ARMY HEALTH CLINIC | ||||||||
| City: | FORT MONMOUTH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325320182 | ||||||||
| FaxNumber: | 7325320194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | RN00114729 | WA | Y | Nursing Service Providers | Registered Nurse | Community Health |
No ID Information.