Healthcare Provider Details

I. General information

NPI: 1346892759
Provider Name (Legal Business Name): MISS REBECCA OLMSTED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14406 NE 20TH AVE
VANCOUVER WA
98686-1448
US

IV. Provider business mailing address

1815 SE 183RD PL
VANCOUVER WA
98683-9710
US

V. Phone/Fax

Practice location:
  • Phone: 360-571-3139
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberD160562836
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: