Basic Information
| Provider Information | |||||||||
| NPI: | 1326791427 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAGUIRE | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | C-CHW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURTON | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 36 SW NYE ST | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973653821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412650445 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1010 SW COAST HWY | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973655288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412650445 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2022 | ||||||||
| LastUpdateDate: | 01/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | THW000106123 | OR | Y | Other Service Providers | Community Health Worker |
No ID Information.