Provider Demographics
NPI:1558509943
Name:COWDEN-KRETZLER, VIRGINIA GERISE (ARNP)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:GERISE
Last Name:COWDEN-KRETZLER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:VIRGINIA
Other - Middle Name:GERISE
Other - Last Name:COWDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 2429
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-8486
Mailing Address - Country:US
Mailing Address - Phone:360-575-8275
Mailing Address - Fax:360-575-1948
Practice Address - Street 1:1044 11TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2506
Practice Address - Country:US
Practice Address - Phone:360-575-8275
Practice Address - Fax:360-575-1948
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004319363LA2200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9621673Medicaid