Healthcare Provider Details

I. General information

NPI: 1851532659
Provider Name (Legal Business Name): FIR CREEK PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 03/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9101 BRIDGEPORT WAY SW BLD A
LAKEWOOD WA
98499-2419
US

IV. Provider business mailing address

9101 BRIDGEPORT WAY SW BLD A
LAKEWOOD WA
98499-2419
US

V. Phone/Fax

Practice location:
  • Phone: 253-565-7686
  • Fax: 253-566-0210
Mailing address:
  • Phone: 253-565-7686
  • Fax: 253-566-0210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberRN00093723
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberAP30003701
License Number StateWA

VIII. Authorized Official

Name: MRS. MICHELLE M HAYES
Title or Position: PEDIATRIC NURSE PRACTITIONER
Credential: MN, ARNP
Phone: 253-565-7686