Healthcare Provider Details

I. General information

NPI: 1831641471
Provider Name (Legal Business Name): ANNA KOWALCZYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL ARMY MEDICAL CTR 9040 JACKSON AVE ATTN: MCHJ-CLQ-C,
TACOMA WA
98431-1100
US

IV. Provider business mailing address

4124 LINCOLN AVE NE
RENTON WA
98056-4201
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-3869
  • Fax:
Mailing address:
  • Phone: 425-643-6766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN00109429
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: