Healthcare Provider Details

I. General information

NPI: 1972032845
Provider Name (Legal Business Name): AMY MARIE WARNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY MARIE BAGWELL

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6811 S 204TH ST STE 280
KENT WA
98032-1352
US

IV. Provider business mailing address

1391 SINCLAIR DR
DUPONT WA
98327-8815
US

V. Phone/Fax

Practice location:
  • Phone: 888-674-5871
  • Fax:
Mailing address:
  • Phone: 205-292-5529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60740006
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: