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General NPI Number Information
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NPI Number | 1184340291
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Entity Type | Organization
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Legal Business Name | THE WELLNESS COOPERATIVE
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Dates
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Enumeration Date | 10/19/2022
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Last Update Date | 10/19/2022
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Provider Practice Location Address
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Address Line | 714 HARRISON AVE
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City | ASTORIA
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State | OR
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Zip | 97103-4738
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Country | US
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Telephone | 503-791-2816
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Fax | 866-638-1928
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Provider Business Mailing Address
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Address Line | 714 HARRISON AVE
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City | ASTORIA
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State | OR
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Zip | 97103-4738
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Country | US
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Telephone | 503-791-2816
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Fax | 866-638-1928
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Authorized Official
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Title or Position | FOUNDING MEMBER, FNP-C
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Name | TONYA LEE FREDERICK
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Credential | APRN
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Telephone | 503-791-2816
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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