Healthcare Provider Details

I. General information

NPI: 1639165681
Provider Name (Legal Business Name): IRENE PREPULA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 06/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18503 NE 219TH ST
BATTLE GROUND WA
98604-9282
US

IV. Provider business mailing address

PO BOX 893
BATTLE GROUND WA
98604-0893
US

V. Phone/Fax

Practice location:
  • Phone: 360-687-5666
  • Fax: 360-666-8346
Mailing address:
  • Phone: 360-687-5666
  • Fax: 360-666-8346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT00000946
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0520
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: