Healthcare Provider Details

I. General information

NPI: 1003944836
Provider Name (Legal Business Name): DANA SHAY THERKILDSEN IDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOONE RD
BREMERTON WA
98312-1894
US

IV. Provider business mailing address

USS JOHN C STENNIS CVN74 PO BOX 67
FPO AP
96615
US

V. Phone/Fax

Practice location:
  • Phone: 360-475-4887
  • Fax: 360-475-4522
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: