Healthcare Provider Details

I. General information

NPI: 1760177026
Provider Name (Legal Business Name): NICOLE R WILLIAMS SUDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/11/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5197 NW LOWER RIVER RD BLDG 1
VANCOUVER WA
98660
US

IV. Provider business mailing address

3303 E EVERGREEN BLVD
VANCOUVER WA
98661-4929
US

V. Phone/Fax

Practice location:
  • Phone: 360-205-1222
  • Fax:
Mailing address:
  • Phone: 360-518-9659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: