Healthcare Provider Details

I. General information

NPI: 1760599609
Provider Name (Legal Business Name): MRS. JEWELENE RAE PATTULLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS JEWELENE RAE HENLINE

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 07/08/2007
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

4805 NE 52ND CIR
VANCOUVER WA
98661-7805
US

V. Phone/Fax

Practice location:
  • Phone: 360-418-6001
  • Fax:
Mailing address:
  • Phone: 360-695-4912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDO00001723
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: