Healthcare Provider Details

I. General information

NPI: 1548562903
Provider Name (Legal Business Name): LORI ROEHL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3907 SUMMITVIEW AVE
YAKIMA WA
98902-2716
US

IV. Provider business mailing address

PO BOX 8051
YAKIMA WA
98908-0051
US

V. Phone/Fax

Practice location:
  • Phone: 509-469-1903
  • Fax: 509-469-1905
Mailing address:
  • Phone: 509-469-1903
  • Fax: 509-469-1905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP30000938
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN00077942
License Number StateWA

VIII. Authorized Official

Name: MRS. LORI CLAUDETTE ROEHL
Title or Position: OWNER / OPERATOR
Credential: ARNP
Phone: 509-452-4650