Provider Demographics
NPI:1639158223
Name:POUPORE, EILEEN LOUISE (NP)
Entity Type:Individual
Prefix:DR
First Name:EILEEN
Middle Name:LOUISE
Last Name:POUPORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 88TH ST E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98446-2507
Mailing Address - Country:US
Mailing Address - Phone:253-312-8923
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98433-9500
Practice Address - Country:US
Practice Address - Phone:253-968-4848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006358363LP0808X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9635384Medicaid
WA8938321OtherCRIME VICTIMS
WA0618POOtherREGENCE BLUE SHIELD
WA8938321OtherCRIME VICTIMS
WA9635384Medicaid