Provider Demographics
NPI:1609905751
Name:INFANT HOME PHOTOTHERAPY
Entity Type:Organization
Organization Name:INFANT HOME PHOTOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GENTRY-HAYWARD
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, MBA-HCA
Authorized Official - Phone:425-355-0957
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-1328
Mailing Address - Country:US
Mailing Address - Phone:425-355-0957
Mailing Address - Fax:
Practice Address - Street 1:4908 33RD AVE W
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-1338
Practice Address - Country:US
Practice Address - Phone:425-355-0957
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIS-342163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty