Healthcare Provider Details

I. General information

NPI: 1760797492
Provider Name (Legal Business Name): KERA SHVONNE SCOTT PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44106 244TH AVE SE
ENUMCLAW WA
98022-9442
US

IV. Provider business mailing address

44106 244TH AVE SE
ENUMCLAW WA
98022-9442
US

V. Phone/Fax

Practice location:
  • Phone: 253-334-9132
  • Fax:
Mailing address:
  • Phone: 253-334-9132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number60038552
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: