Healthcare Provider Details

I. General information

NPI: 1790119675
Provider Name (Legal Business Name): RAQUEL MARISOL BOLENDER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2013
Last Update Date: 11/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 S UNION AVE
TACOMA WA
98405-1954
US

IV. Provider business mailing address

1530 S UNION AVE
TACOMA WA
98405-1954
US

V. Phone/Fax

Practice location:
  • Phone: 253-759-5340
  • Fax:
Mailing address:
  • Phone: 253-759-5340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP60409450
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP60409450
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: