Provider Demographics
NPI:1639236318
Name:GODJIKIAN, CONNIE F (ARNP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:F
Last Name:GODJIKIAN
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 1:2420 S UNION AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1322
Mailing Address - Country:US
Mailing Address - Phone:253-272-8148
Mailing Address - Fax:253-404-0506
Practice Address - Street 1:3209 S 23RD ST
Practice Address - Street 2:SUITE 340
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1602
Practice Address - Country:US
Practice Address - Phone:253-272-8148
Practice Address - Fax:253-404-0506
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007488363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP30007488OtherWA LICENSE
WA9651779Medicaid
WAG8851594Medicare PIN
WAAP30007488OtherWA LICENSE
WA9651779Medicaid
WAG8879088Medicare PIN
WA001045700Medicare PIN
WA000188100Medicare PIN
WAG8851595Medicare PIN
WAG8851596Medicare PIN
WAG8851597Medicare PIN
WA8851594Medicare PIN
WAP00424497Medicare PIN