Healthcare Provider Details

I. General information

NPI: 1255259040
Provider Name (Legal Business Name): MICHELLE VANDERPOOL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE CALLERO

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S J ST
TACOMA WA
98405-4933
US

IV. Provider business mailing address

11708 139TH STREET CT E
PUYALLUP WA
98374-4720
US

V. Phone/Fax

Practice location:
  • Phone: 253-503-9417
  • Fax:
Mailing address:
  • Phone: 253-503-9417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LS0200X
TaxonomySchool Nurse Practitioner
License NumberRN60499190
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: