Provider Demographics
NPI:1073799375
Name:VANTINE, JAIME MELLOR (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JAIME
Middle Name:MELLOR
Last Name:VANTINE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JAIME
Other - Middle Name:MELLOR
Other - Last Name:ROCHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1210 W FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:WA
Mailing Address - Zip Code:99111-9552
Mailing Address - Country:US
Mailing Address - Phone:509-397-4717
Mailing Address - Fax:509-397-3501
Practice Address - Street 1:1210 W FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:WA
Practice Address - Zip Code:99111-9552
Practice Address - Country:US
Practice Address - Phone:509-397-4717
Practice Address - Fax:509-397-3501
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60393668363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01223246Medicare PIN