Healthcare Provider Details

I. General information

NPI: 1649402942
Provider Name (Legal Business Name): INTEGRATED FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 108TH ST SW
LAKEWOOD WA
98499-3724
US

IV. Provider business mailing address

PO BOX 98886
LAKEWOOD WA
98496-8886
US

V. Phone/Fax

Practice location:
  • Phone: 253-589-6573
  • Fax: 253-984-1079
Mailing address:
  • Phone: 509-389-6945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP30006855
License Number StateWA

VIII. Authorized Official

Name: TRACI MICHELLE MANCUSO
Title or Position: FAMILY NURSE PRACTITIONER
Credential: ARNP
Phone: 509-389-6945