Healthcare Provider Details

I. General information

NPI: 1588164925
Provider Name (Legal Business Name): NORTHWEST PEDIATRIC DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 LILLY RD NE STE 105
OLYMPIA WA
98506-5191
US

IV. Provider business mailing address

PO BOX 2314
OLYMPIA WA
98507-2314
US

V. Phone/Fax

Practice location:
  • Phone: 360-539-6141
  • Fax:
Mailing address:
  • Phone:
  • 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: DR. VIVIAN LOMBILLO
Title or Position: PHYSICIAN/OWNER
Credential: MD
Phone: 360-539-6141