=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912606237
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE SWEET LIFE ADVANCED DIABETES MANAGEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2023
-----------------------------------------------------
Last Update Date | 08/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4110 61ST CT SW
-----------------------------------------------------
City | TUMWATER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98512-7043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-772-3715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4110 61ST CT SW
-----------------------------------------------------
City | TUMWATER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98512-7043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-772-3715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JESSICA RYAN
-----------------------------------------------------
Credential | RN,NP,AANP
-----------------------------------------------------
Telephone | 808-772-3715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------