Healthcare Provider Details

I. General information

NPI: 1043023401
Provider Name (Legal Business Name): JILLIAN DIANE OKUMURA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JILLIAN DIANE ANTES RN

II. Dates (important events)

Enumeration Date: 01/29/2025
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3714 19TH AVENUE CT SE
PUYALLUP WA
98372-4232
US

IV. Provider business mailing address

3714 19TH AVENUE CT SE
PUYALLUP WA
98372-4232
US

V. Phone/Fax

Practice location:
  • Phone: 808-756-2108
  • Fax:
Mailing address:
  • Phone: 808-756-2108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number60606094
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: