Healthcare Provider Details

I. General information

NPI: 1013938620
Provider Name (Legal Business Name): VIVIAN A LOMBILLO MD PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 LILLY RD NE SUITE 105 NORTHWEST PEDIATRIC DERMATOLOGY, PLLC
OLYMPIA WA
98506
US

IV. Provider business mailing address

703 LILLY RD NE SUITE 105 NORTHWEST PEDIATRIC DERMATOLOGY, PLLC
OLYMPIA WA
98506
US

V. Phone/Fax

Practice location:
  • Phone: 360-539-6141
  • Fax:
Mailing address:
  • Phone: 360-539-6141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD00046225
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberMD00046225
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: