Provider Demographics
NPI:1780861112
Name:WILBURN, PATRICIA ANNE (LMP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANNE
Last Name:WILBURN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 15142
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98511-5142
Mailing Address - Country:US
Mailing Address - Phone:360-584-3889
Mailing Address - Fax:
Practice Address - Street 1:1820 BLACK LAKE BLVD SW
Practice Address - Street 2:#103
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98512-5619
Practice Address - Country:US
Practice Address - Phone:360-584-3889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00025187174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist