Healthcare Provider Details

I. General information

NPI: 1548080849
Provider Name (Legal Business Name): MRS. AYANNA JUSTINE COLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2024
Last Update Date: 10/12/2024
Certification Date: 10/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 W FRANKLIN ST
SHELTON WA
98584-3504
US

IV. Provider business mailing address

260 NE MAHONIA DR
BELFAIR WA
98528-9673
US

V. Phone/Fax

Practice location:
  • Phone: 360-763-5610
  • Fax:
Mailing address:
  • Phone: 253-736-4312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: