=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093463416
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURISSA DEANNE WOERDEMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2022
-----------------------------------------------------
Last Update Date | 03/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4815 N ASSEMBLY ST
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99205-6185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-822-8552
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4815 N ASSEMBLY ST
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99205-6185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-462-2500
-----------------------------------------------------
Fax | 509-462-2500
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------