1629327382 NPI number — KRISTEN FAITH FAHNSTROM M.A. CCC-SLP

NPI Number: 1629327382
Health Care Provider/Practitioner: KRISTEN FAITH FAHNSTROM M.A. CCC-SLP

NPI Number : 1629327382 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1629327382",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "FAHNSTROM",
    "FirstName": "KRISTEN",
    "MiddleName": "FAITH",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "M.A. CCC-SLP",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "MACKLEY",
    "OtherFirstName": "KRISTEN",
    "OtherMiddleName": "FAITH",
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": "MA CCC-SLP",
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "661 CAMBRIDGE WAY",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "BOLINGBROOK",
    "MailingAddressStateName": "IL",
    "MailingAddressPostalCode": "60440-1058",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": null,
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "2 WESTBROOK CORPORATE CTR STE 800",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "WESTCHESTER",
    "PracticeLocationAddressStateName": "IL",
    "PracticeLocationAddressPostalCode": "60154-5702",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "800-714-0040",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "09/09/2012",
    "LastUpdateDate": "07/14/2020",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "235Z00000X",
          "TaxonomyName": "Speech-Language Pathologist",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "235Z00000X",
          "TaxonomyName": "Speech-Language Pathologist",
          "LicenseNumber": "146011275",
          "LicenseNumberStateCode": "IL",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}