Healthcare Provider Details

I. General information

NPI: 1558724005
Provider Name (Legal Business Name): MR. LAWRENCE CEDETTE LITTLE III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LAWRENCE CEDETTE LITTLE III COTA/L

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 04/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N MEDCALF LN
MONTESANO WA
98563-1318
US

IV. Provider business mailing address

1201 N FAIRFIELD ST
ABERDEEN WA
98520-3018
US

V. Phone/Fax

Practice location:
  • Phone: 360-249-2273
  • Fax:
Mailing address:
  • Phone: 360-637-8947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberOC60264322
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: