Healthcare Provider Details

I. General information

NPI: 1114241478
Provider Name (Legal Business Name): PACIFIC LUTHERAN UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2010
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12108 S PARK AVE
TACOMA WA
98447-0001
US

IV. Provider business mailing address

12108 S PARK AVE
TACOMA WA
98447-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-535-7337
  • Fax: 253-536-5042
Mailing address:
  • Phone: 253-535-7337
  • Fax: 253-536-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number60128007
License Number StateWA

VIII. Authorized Official

Name: MS. AUDRY JEAN KAHLSTROM
Title or Position: ARNP
Credential: MN
Phone: 253-389-6998