Provider Demographics
NPI:1609340660
Name:NDERITU, CAROLYNE
Entity Type:Individual
Prefix:
First Name:CAROLYNE
Middle Name:
Last Name:NDERITU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44181
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98448-0181
Mailing Address - Country:US
Mailing Address - Phone:253-228-2737
Mailing Address - Fax:
Practice Address - Street 1:10202 PACIFIC AVE S STE 210
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-6573
Practice Address - Country:US
Practice Address - Phone:253-228-2737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-13
Last Update Date:2019-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201810289LPN164W00000X
WALP60500714164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse