Provider Demographics
NPI:1417002353
Name:CARLSON, MIFAWNWY (LM)
Entity Type:Individual
Prefix:
First Name:MIFAWNWY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12270 OLALLA VALLEY RD SE
Mailing Address - Street 2:
Mailing Address - City:OLALLA
Mailing Address - State:WA
Mailing Address - Zip Code:98359-9748
Mailing Address - Country:US
Mailing Address - Phone:253-857-6359
Mailing Address - Fax:253-857-6359
Practice Address - Street 1:12270 OLALLA VALLEY RD SE
Practice Address - Street 2:
Practice Address - City:OLALLA
Practice Address - State:WA
Practice Address - Zip Code:98359-9748
Practice Address - Country:US
Practice Address - Phone:253-857-6359
Practice Address - Fax:253-857-6359
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMW00000061176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife