Provider Demographics
NPI:1629295282
Name:PROUSE, DYAN NICOLE (DPT)
Entity Type:Individual
Prefix:DR
First Name:DYAN
Middle Name:NICOLE
Last Name:PROUSE
Suffix:
Gender:F
Credentials:DPT
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 921
Mailing Address - Street 2:
Mailing Address - City:VASHON
Mailing Address - State:WA
Mailing Address - Zip Code:98070-0921
Mailing Address - Country:US
Mailing Address - Phone:206-463-1100
Mailing Address - Fax:206-463-1100
Practice Address - Street 1:17141 VASHON HWY SW
Practice Address - Street 2:# 103
Practice Address - City:VASHON
Practice Address - State:WA
Practice Address - Zip Code:98070-4603
Practice Address - Country:US
Practice Address - Phone:206-463-3441
Practice Address - Fax:206-463-3089
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00007497174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8340178Medicaid
WAAB33726Medicare ID - Type Unspecified