{
"Npi": {
"NPI": "1306368907",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "OWENS",
"FirstName": "TELLY",
"MiddleName": "LESHAN",
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "4331 BATHGATE RD",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "RICHMOND",
"MailingAddressStateName": "VA",
"MailingAddressPostalCode": "23234-3581",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "804-549-9115",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "1405 WESTOVER HILLS BLVD STE 1A",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "RICHMOND",
"PracticeLocationAddressStateName": "VA",
"PracticeLocationAddressPostalCode": "23225-3153",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "804-424-3260",
"PracticeLocationAddressFaxNumber": "804-424-3261",
"EnumerationDate": "07/14/2017",
"LastUpdateDate": "09/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "246RP1900X",
"TaxonomyName": "Phlebotomy Technician",
"LicenseNumber": "752156",
"LicenseNumberStateCode": "VA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}