Healthcare Provider Details

I. General information

NPI: 1043557333
Provider Name (Legal Business Name): FREELAND PRIMARY CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5577 VANBARR PL
FREELAND WA
98249-9555
US

IV. Provider business mailing address

PO BOX 935
FREELAND WA
98249-0935
US

V. Phone/Fax

Practice location:
  • Phone: 360-331-3343
  • Fax: 360-331-3373
Mailing address:
  • Phone: 360-331-3343
  • Fax: 360-331-3373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY JOHNSON
Title or Position: PRACTICE MANAGER
Credential:
Phone: 360-331-3343