Provider Demographics
NPI:1114241478
Name:PACIFIC LUTHERAN UNIVERSITY
Entity Type:Organization
Organization Name:PACIFIC LUTHERAN UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:MS
Authorized Official - First Name:AUDRY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:KAHLSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MN
Authorized Official - Phone:253-389-6998
Mailing Address - Street 1:12108 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98447-0001
Mailing Address - Country:US
Mailing Address - Phone:253-535-7337
Mailing Address - Fax:253-536-5042
Practice Address - Street 1:12108 S PARK AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98447-0001
Practice Address - Country:US
Practice Address - Phone:253-535-7337
Practice Address - Fax:253-536-5042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60128007261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health