Healthcare Provider Details

I. General information

NPI: 1295006187
Provider Name (Legal Business Name): SPECIALTY WOUND AND FOOT CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2012
Last Update Date: 01/24/2012
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

4901 108TH ST SW
LAKEWOOD WA
98499-3724
US

V. Phone/Fax

Practice location:
  • Phone: 253-584-3577
  • Fax:
Mailing address:
  • Phone: 253-584-3577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP300003906
License Number StateWA

VIII. Authorized Official

Name: SHIRLEY B CAMERON
Title or Position: OWNER/PROVIDER
Credential: GNP
Phone: 253-536-2504