Healthcare Provider Details

I. General information

NPI: 1104155837
Provider Name (Legal Business Name): MRS. BROOKE OLIVIA ORTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3709 APOLLO ST SE
LACEY WA
98503-7137
US

IV. Provider business mailing address

3709 APOLLO ST SE
LACEY WA
98503-7137
US

V. Phone/Fax

Practice location:
  • Phone: 360-556-4456
  • Fax:
Mailing address:
  • Phone: 360-556-4456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number602573980
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: