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General NPI Number Information
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NPI Number | 1245957018
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Entity Type | Individual
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Provider Name | DALLAS R COURSEY SUDPT
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Gender | Female
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Dates
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Enumeration Date | 10/24/2022
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Last Update Date | 06/27/2023
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Provider Practice Location Address
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Address Line | 851 POPLAR PL S
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City | SEATTLE
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State | WA
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Zip | 98144-2827
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Country | US
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Telephone | 206-322-2387
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Fax |
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Provider Business Mailing Address
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Address Line | 15508 FAIR OAKS DR S
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City | SPANAWAY
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State | WA
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Zip | 98387-9051
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Country | US
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Telephone | 307-871-9786
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | CO61361005
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License Number State | WY
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