Healthcare Provider Details

I. General information

NPI: 1215222591
Provider Name (Legal Business Name): SUSANNA R MIREL ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHOSHANA R MIREL ARNP

II. Dates (important events)

Enumeration Date: 06/14/2011
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13451 SE 36TH ST
BELLEVUE WA
98006-1475
US

IV. Provider business mailing address

971 11TH AVE
LONGVIEW WA
98632-2503
US

V. Phone/Fax

Practice location:
  • Phone: 425-562-1337
  • Fax: 425-562-1331
Mailing address:
  • Phone: 360-577-1771
  • Fax: 360-423-1405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP60223340
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: