Basic Information
Provider Information | |||||||||
NPI: | 1457708224 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THOMAS | ||||||||
FirstName: | KELSEY | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HASENBANK | ||||||||
OtherFirstName: | KELSEY | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 73265 CONFEDERATED WAY | ||||||||
Address2: |   | ||||||||
City: | PENDLETON | ||||||||
State: | OR | ||||||||
PostalCode: | 978019099 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5419669830 | ||||||||
FaxNumber: | 5412787568 | ||||||||
Practice Location | |||||||||
Address1: | 46314 TIMINE WAY | ||||||||
Address2: |   | ||||||||
City: | PENDLETON | ||||||||
State: | OR | ||||||||
PostalCode: | 97801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5419669830 | ||||||||
FaxNumber: | 5412787568 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/20/2016 | ||||||||
LastUpdateDate: | 04/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 376K00000X |   |   | Y |   | Nursing Service Related Providers | Nurse's Aide |   |
No ID Information.