Healthcare Provider Details

I. General information

NPI: 1629325204
Provider Name (Legal Business Name): ELIZABETH FORMAN SERDAR ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 LILLY RD NE STE C
OLYMPIA WA
98506-5080
US

IV. Provider business mailing address

200 LILLY RD NE STE C
OLYMPIA WA
98506-5080
US

V. Phone/Fax

Practice location:
  • Phone: 360-918-8336
  • Fax: 360-972-2152
Mailing address:
  • Phone: 360-481-7788
  • Fax: 360-972-2152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60301000
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP 60301000
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: