Healthcare Provider Details

I. General information

NPI: 1093276123
Provider Name (Legal Business Name): ANNETTE PEARL VILLE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 11TH AVE
LONGVIEW WA
98632-2503
US

IV. Provider business mailing address

971 11TH AVE
LONGVIEW WA
98632-2503
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-6140
  • Fax:
Mailing address:
  • Phone: 360-423-6140
  • Fax: 360-423-1405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberT1877
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: