MEDICARE: ATOMIC DERMATOLOGY LLC

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	363L00000X	Nurse Practitioner	AP60211812	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770009706
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATOMIC DERMATOLOGY LLC

Provider Business Mailing Address
First Line	:	7224 SANDY RIDGE RD
Second Line	:
City	:	PASCO
State	:	WA
Zip	:	99301-9379
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9221 SANDIFUR PKWY STE A
Second Line	:
City	:	PASCO
State	:	WA
Zip	:	99301-9241
Country	:	US
Telephone Number	:	509-233-7546
Fax Number	:	509-795-3508

Authorized Official
Title or Position	:	OWNER
Name	:	VICKI HAINES
Credential	:	DCNP
Telephone Number	:	509-301-6451

Provider Enumeration Date	:	08/22/2017
Last Update Date	:	01/09/2023

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Directions to “ATOMIC DERMATOLOGY LLC ” Practice Location

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