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General NPI Number Information
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NPI Number | 1750639704
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Entity Type | Organization
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Legal Business Name | EVERGREEN CHILDREN'S CLINIC
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Dates
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Enumeration Date | 08/23/2012
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Last Update Date | 08/23/2012
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Provider Practice Location Address
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Address Line | 1910 MERIDIAN ST S SUITE A
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City | PUYALLUP
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State | WA
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Zip | 98371-7531
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Country | US
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Telephone | 253-848-2303
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Fax | 253-848-8956
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Provider Business Mailing Address
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Address Line | 1910 MERIDIAN ST S SUITE A
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City | PUYALLUP
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State | WA
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Zip | 98371-7531
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Country | US
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Telephone | 253-848-2303
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Fax | 253-848-8956
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. SUSANNE I ROACH
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Credential |
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Telephone | 253-848-2303
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | AP60305667
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License Number State | WA
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