Healthcare Provider Details

I. General information

NPI: 1689850190
Provider Name (Legal Business Name): ARDITH LOUISE CONWAY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 12/14/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 WASHINGTON AVE
ENUMCLAW WA
98022-3547
US

IV. Provider business mailing address

1112 WASHINGTON AVE
ENUMCLAW WA
98022-3547
US

V. Phone/Fax

Practice location:
  • Phone: 503-806-7148
  • Fax:
Mailing address:
  • Phone: 503-806-7148
  • Fax: 360-284-2542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number60291192
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60291192
License Number StateWA

VII. Legacy identifiers

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

# 1
Identifier2016230
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: