1689230401 NPI number — CARLEIGH MARIE CAMERON PRATT

Table of content: CARLEIGH MARIE CAMERON PRATT (NPI 1689230401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689230401 NPI number — CARLEIGH MARIE CAMERON PRATT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRATT
Provider First Name:
CARLEIGH
Provider Middle Name:
MARIE CAMERON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CAMERON
Provider Other First Name:
CARLEIGH
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689230401
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 34703
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124-1703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6004 CAPITOL BLVD SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUMWATER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98501-8520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-704-7580
Provider Business Practice Location Address Fax Number:
360-704-7567
Provider Enumeration Date:
05/16/2019

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: 106H00000X , with the licence number:  LF61330299 , 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)

  • Identifier: 2135081 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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