Healthcare Provider Details

I. General information

NPI: 1124063847
Provider Name (Legal Business Name): MRS. CINDA JO BOLETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5439 6TH AVE NW
TULALIP WA
98271-6530
US

IV. Provider business mailing address

5439 6TH AVE NW
TULALIP WA
98271-6530
US

V. Phone/Fax

Practice location:
  • Phone: 360-659-7003
  • Fax:
Mailing address:
  • Phone: 360-659-7003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberVA00058647
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: