1104133545 NPI number — MRS. CARMEN RAE WOOLMAN BS, CDP

Table of content: MRS. CARMEN RAE WOOLMAN BS, CDP (NPI 1104133545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104133545 NPI number — MRS. CARMEN RAE WOOLMAN BS, CDP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOOLMAN
Provider First Name:
CARMEN
Provider Middle Name:
RAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BS, CDP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BARR
Provider Other First Name:
CARMEN
Provider Other Middle Name:
RAE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
BS, CDP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104133545
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2610 WETMORE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98201-2927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-258-5270
Provider Business Mailing Address Fax Number:
425-258-5275

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2610 WETMORE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98201-2927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-258-5270
Provider Business Practice Location Address Fax Number:
425-258-5275
Provider Enumeration Date:
09/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  CP60266906 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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