Basic Information
Provider Information | |||||||||
NPI: | 1669634911 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HITTLE | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | MARIA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LORIMOR | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | MARIA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 356 | ||||||||
Address2: |   | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672010356 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003745326 | ||||||||
FaxNumber: | 8003747656 | ||||||||
Practice Location | |||||||||
Address1: | 929 N SAINT FRANCIS ST | ||||||||
Address2: |   | ||||||||
City: | WICHITA | ||||||||
State: | KS | ||||||||
PostalCode: | 672143821 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003745326 | ||||||||
FaxNumber: | 8003747656 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2008 | ||||||||
LastUpdateDate: | 02/19/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 367500000X | 55673 | KS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | P00660630 | 01 | KS | RR MEDICARE GROUP CQ2302 | OTHER | 200574820A | 05 | KS |   | MEDICAID |