Healthcare Provider Details

I. General information

NPI: 1851917991
Provider Name (Legal Business Name): PROSSY NAGERI BALOME
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 FAWCETT AVE STE 100
TACOMA WA
98402-5502
US

IV. Provider business mailing address

721 FAWCETT AVE STE 100
TACOMA WA
98402-5502
US

V. Phone/Fax

Practice location:
  • Phone: 253-230-4351
  • Fax:
Mailing address:
  • Phone: 253-230-4351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.LP.70151200
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: