Healthcare Provider Details

I. General information

NPI: 1306832274
Provider Name (Legal Business Name): TINA M TAYLOR ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINA M HUDSON ARNP

II. Dates (important events)

Enumeration Date: 09/26/2005
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 11TH AVE STE B
LONGVIEW WA
98632-2555
US

IV. Provider business mailing address

PO BOX 2429
LONGVIEW WA
98632-8486
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-8600
  • Fax: 360-636-7372
Mailing address:
  • Phone: 360-575-8275
  • Fax: 360-575-1950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN00113328
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP30006904
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: