Provider Demographics
NPI:1275809550
Name:WILD ROSE CLINIC INC
Entity Type:Organization
Organization Name:WILD ROSE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:REBEKAH
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERSON
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP, CNM
Authorized Official - Phone:509-460-4823
Mailing Address - Street 1:PO BOX 6762
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-0640
Mailing Address - Country:US
Mailing Address - Phone:509-460-4823
Mailing Address - Fax:509-460-4833
Practice Address - Street 1:711 S AUBURN ST STE P
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-5665
Practice Address - Country:US
Practice Address - Phone:509-460-4823
Practice Address - Fax:509-460-4833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003677363LF0000X, 363LW0102X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty