Provider Demographics
NPI:1487045290
Name:NISHIMURA, TEPAPORN (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:TEPAPORN
Middle Name:
Last Name:NISHIMURA
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 VASHON AVE NE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16022 116TH AVE SE
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-5245
Practice Address - Country:US
Practice Address - Phone:425-204-3352
Practice Address - Fax:425-204-3357
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-16
Last Update Date:2015-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60017388163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA231428Medicaid