Healthcare Provider Details

I. General information

NPI: 1861939886
Provider Name (Legal Business Name): TERRA FORWARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2017
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
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
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-6104
  • Fax:
Mailing address:
  • Phone: 253-968-6104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number1848
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: