=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366088601
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLUMBIA RIVER PRIMARY CARE AND AESTHETICS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2019
-----------------------------------------------------
Last Update Date | 02/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3501 ROAD 68 STE 4
-----------------------------------------------------
City | PASCO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99301-1973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-542-7932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2651
-----------------------------------------------------
City | PASCO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99302-2651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NICHOLE M. SHARP
-----------------------------------------------------
Credential | DNP-FNP, ARNP
-----------------------------------------------------
Telephone | 509-366-0786
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------