MEDICARE: NICHELLE LAZETTE BUCHANAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	CG61504949	WY
2	101YS0200X	School Counselor
3	101Y00000X	Counselor	CG61504949	WA

General Provider Information

NPI Number	:	1548002728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHELLE LAZETTE BUCHANAN

Provider Business Mailing Address
First Line	:	610 SO. YAKIMA STREET
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98405
Country	:	US
Telephone Number	:	253-396-5800
Fax Number	:

Provider Business Practice Location Address
First Line	:	610 SO. YAKIMA STREET
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98405
Country	:	US
Telephone Number	:	253-396-5800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2024
Last Update Date	:	03/23/2026

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