Healthcare Provider Details

I. General information

NPI: 1417002353
Provider Name (Legal Business Name): MIFAWNWY CARLSON L.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12270 OLALLA VALLEY RD SE
OLALLA WA
98359-9748
US

IV. Provider business mailing address

12270 OLALLA VALLEY RD SE
OLALLA WA
98359-9748
US

V. Phone/Fax

Practice location:
  • Phone: 253-857-6359
  • Fax: 253-857-6359
Mailing address:
  • Phone: 253-857-6359
  • Fax: 253-857-6359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMW00000061
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: