1962782094 NPI number — MRS. NICOLE MARIE EVANS LMP

Table of content: KATRINA HENSON (NPI 1720792161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962782094 NPI number — MRS. NICOLE MARIE EVANS LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
NICOLE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMAS
Provider Other First Name:
NICOLE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA60239028
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962782094
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7401 CANYON RD E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUYALLUP
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98371-4906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-840-9444
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18801 VETERANS MEMORIAL DR E
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
BONNEY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98391-5204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-840-9444
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/20/2011

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: 225700000X , with the licence number:  MA60239028 , 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)