Healthcare Provider Details

I. General information

NPI: 1558005223
Provider Name (Legal Business Name): LYSSA SPURGEON RN, MPH, BSN, CEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

9040 JACKSON AVE
TACOMA WA
98431-3900
US

V. Phone/Fax

Practice location:
  • Phone: 253-341-0294
  • Fax:
Mailing address:
  • Phone: 253-968-2252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number61284767
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number583842
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: