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General NPI Number Information
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NPI Number | 1588164925
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Entity Type | Organization
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Legal Business Name | NORTHWEST PEDIATRIC DERMATOLOGY, PLLC
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Dates
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Enumeration Date | 02/12/2018
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Last Update Date | 02/12/2018
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Provider Practice Location Address
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Address Line | 703 LILLY RD NE STE 105
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City | OLYMPIA
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State | WA
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Zip | 98506-5191
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Country | US
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Telephone | 360-539-6141
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2314
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City | OLYMPIA
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State | WA
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Zip | 98507-2314
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. VIVIAN LOMBILLO
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Credential | MD
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Telephone | 360-539-6141
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | MD00046225
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 207NP0225X
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Taxonomy Name | Pediatric Dermatology Physician
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License Number | MD00046225
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License Number State | WA
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