Basic Information
Provider Information | |||||||||
NPI: | 1821566159 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NOBLE | ||||||||
FirstName: | PEGGY | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEWIS | ||||||||
OtherFirstName: | PEGGY | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CNA | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1960 THOMPSON DR | ||||||||
Address2: |   | ||||||||
City: | SEDRO WOOLLEY | ||||||||
State: | WA | ||||||||
PostalCode: | 982845007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608563186 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1960 THOMPSON DR | ||||||||
Address2: |   | ||||||||
City: | SEDRO WOOLLEY | ||||||||
State: | WA | ||||||||
PostalCode: | 982845007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608563186 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/05/2018 | ||||||||
LastUpdateDate: | 11/05/2018 | ||||||||
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 | 246ZA2600X | NC10101914 | WA | Y |   | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Art, Medical |
No ID Information.