Provider Demographics
NPI:1033324157
Name:MORTELL, PATRICIA K
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:K
Last Name:MORTELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9825
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98666-8825
Mailing Address - Country:US
Mailing Address - Phone:360-397-8000
Mailing Address - Fax:360-397-8110
Practice Address - Street 1:1601 E FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3753
Practice Address - Country:US
Practice Address - Phone:360-397-8000
Practice Address - Fax:360-397-8110
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001092133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8265498Medicaid