Basic Information
Provider Information
NPI: 1003004797
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KOLK
FirstName: DEBORAH
MiddleName: KAY
NamePrefix:  
NameSuffix:  
Credential: R.N.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 204 DEPAUL CT
Address2:  
City: LAS VEGAS
State: NV
PostalCode: 891444136
CountryCode: US
TelephoneNumber: 7022542029
FaxNumber:  
Practice Location
Address1: 204 DEPAUL CT
Address2:  
City: LAS VEGAS
State: NV
PostalCode: 891444136
CountryCode: US
TelephoneNumber: 7022542029
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/09/2007
LastUpdateDate: 10/09/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163W00000XRN31350NVY Nursing Service ProvidersRegistered Nurse 

No ID Information.


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