Healthcare Provider Details

I. General information

NPI: 1043865421
Provider Name (Legal Business Name): MARINA VIKTOROVNA DOLMATOVA ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2019
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2622 S MERIDIAN
PUYALLUP WA
98373-1500
US

IV. Provider business mailing address

1793 13TH ST SE
SALEM OR
97302-2541
US

V. Phone/Fax

Practice location:
  • Phone: 253-841-2453
  • Fax: 253-840-5519
Mailing address:
  • Phone: 503-362-8385
  • Fax: 503-362-8435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN60656201
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61194717
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: