Healthcare Provider Details

I. General information

NPI: 1073809091
Provider Name (Legal Business Name): ANNA GAVRISHOVA MA, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9407 NE VANCOUVER MALL DR STE 208
VANCOUVER WA
98662-6191
US

IV. Provider business mailing address

9407 NE VANCOUVER MALL DR STE 208
VANCOUVER WA
98662-6191
US

V. Phone/Fax

Practice location:
  • Phone: 360-559-1468
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61351967
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: