Healthcare Provider Details

I. General information

NPI: 1720692445
Provider Name (Legal Business Name): EDITH GAVINO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11506 NE 125TH AVE
VANCOUVER WA
98682-2092
US

IV. Provider business mailing address

11506 NE 125TH AVE
VANCOUVER WA
98682-2092
US

V. Phone/Fax

Practice location:
  • Phone: 360-869-3061
  • Fax:
Mailing address:
  • Phone: 360-869-3061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number604613676
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: