Provider Demographics
NPI:1629325204
Name:FORMAN SERDAR, ELIZABETH (ARNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:FORMAN SERDAR
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 LILLY RD NE STE C
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5080
Mailing Address - Country:US
Mailing Address - Phone:360-481-7788
Mailing Address - Fax:360-972-2152
Practice Address - Street 1:200 LILLY RD NE STE C
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5080
Practice Address - Country:US
Practice Address - Phone:360-918-8336
Practice Address - Fax:360-972-2152
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60301000363LP0808X
WAAP 60301000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2025519Medicaid
WA304788OtherL & I WA
WA2025519Medicaid