Healthcare Provider Details

I. General information

NPI: 1801361126
Provider Name (Legal Business Name): VINCENT PETER OTUNDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2018
Last Update Date: 07/15/2025
Certification Date: 07/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E PIONEER
PUYALLUP WA
98372-3265
US

IV. Provider business mailing address

325 E PIONEER
PUYALLUP WA
98372-3265
US

V. Phone/Fax

Practice location:
  • Phone: 253-697-8400
  • Fax: 253-697-3730
Mailing address:
  • Phone: 253-697-8400
  • Fax: 253-697-3730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN60443108
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61018852
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: