=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295361335
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAITLIN RICHARDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2020
-----------------------------------------------------
Last Update Date | 03/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | NAVAJO ROUTE 64 & 12
-----------------------------------------------------
City | TSAILE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86556-8655
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-724-3904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX C021
-----------------------------------------------------
City | TSAILE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86556-5048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-724-3904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Pharmacology Physician
-----------------------------------------------------
License Number | 2019028681
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------