Healthcare Provider Details

I. General information

NPI: 1194485730
Provider Name (Legal Business Name): MRS. CARRERA LEIGH HOBSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2021
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 PACIFIC AVE S STE C
KELSO WA
98626-1638
US

IV. Provider business mailing address

PO BOX 504
WHITE SALMON WA
98672-0504
US

V. Phone/Fax

Practice location:
  • Phone: 360-644-1047
  • Fax:
Mailing address:
  • Phone: 366-773-3780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP60200424
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: