Healthcare Provider Details

I. General information

NPI: 1326477324
Provider Name (Legal Business Name): THOA PHAN FENTON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2013
Last Update Date: 12/10/2019
Certification Date: 12/10/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 COLBY AVE MEDICAL STAFF OFFICE
EVERETT WA
98201-1665
US

IV. Provider business mailing address

PO BOX 5127
EVERETT WA
98206-5127
US

V. Phone/Fax

Practice location:
  • Phone: 425-261-2000
  • Fax:
Mailing address:
  • Phone: 425-261-2000
  • Fax: 425-261-4078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60627377
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP60627377
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberH124638
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberJ124638
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP60627377
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: