Healthcare Provider Details

I. General information

NPI: 1316395171
Provider Name (Legal Business Name): NATALIA IVANOVA ACNPC-AG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 S CEDAR ST STE 101
TACOMA WA
98405-2302
US

IV. Provider business mailing address

1959 NE PACIFIC ST
SEATTLE WA
98195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 347-241-9325
  • Fax:
Mailing address:
  • Phone: 347-241-9325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP61578561
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number715501
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: