1649453234 NPI number — HENEDINE CLARK HERNANDO ARNP

Table of content: HENEDINE CLARK HERNANDO ARNP (NPI 1649453234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649453234 NPI number — HENEDINE CLARK HERNANDO ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERNANDO
Provider First Name:
HENEDINE
Provider Middle Name:
CLARK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649453234
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1608 S J ST FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405-4930
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-207-4200
Provider Business Mailing Address Fax Number:
253-207-4285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 S UNION AVE
Provider Second Line Business Practice Location Address:
A221
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-1702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-459-6231
Provider Business Practice Location Address Fax Number:
253-459-6858
Provider Enumeration Date:
12/06/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  AP60212754 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: AP60212754 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP60212754 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2012633 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".