=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508030180
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAULINE FLOURNOY CARE GIVER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2008
-----------------------------------------------------
Last Update Date | 04/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28121 14TH AVE E
-----------------------------------------------------
City | ROY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-843-2989
-----------------------------------------------------
Fax | 253-843-3087
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28121 14TH AVE E
-----------------------------------------------------
City | ROY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98580
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-843-2989
-----------------------------------------------------
Fax | 253-843-3087
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 138000
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------