Healthcare Provider Details

I. General information

NPI: 1336225283
Provider Name (Legal Business Name): CHRISTA LOUISE MCVICKER LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 BENDIGO BLVD. N. #3
NORTH BEND WA
98045
US

IV. Provider business mailing address

PO BOX 579
NORTH BEND WA
98045-0579
US

V. Phone/Fax

Practice location:
  • Phone: 425-241-0196
  • Fax:
Mailing address:
  • Phone: 425-241-0196
  • Fax: 425-831-2244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA00017671
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: