MEDICARE: MIKAYLA PAIGE WALRATH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		WA

General Provider Information

NPI Number	:	1447105416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKAYLA PAIGE WALRATH

Provider Business Mailing Address
First Line	:	1241 HAYSTACK AVE SE
Second Line	:
City	:	NORTH BEND
State	:	WA
Zip	:	98045-5018
Country	:	US
Telephone Number	:	360-922-4474
Fax Number	:

Provider Business Practice Location Address
First Line	:	1241 HAYSTACK AVE SE
Second Line	:
City	:	NORTH BEND
State	:	WA
Zip	:	98045-5018
Country	:	US
Telephone Number	:	360-922-4474
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2026
Last Update Date	:	03/03/2026

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