Provider Demographics
NPI:1821248402
Name:PROVIDENCE
Entity Type:Organization
Organization Name:PROVIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR/L
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTAL
Authorized Official - Middle Name:CORRINE
Authorized Official - Last Name:MARSON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:360-386-8061
Mailing Address - Street 1:5019 126TH ST. NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98271
Mailing Address - Country:US
Mailing Address - Phone:360-386-8061
Mailing Address - Fax:
Practice Address - Street 1:5019 126TH ST NE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-9062
Practice Address - Country:US
Practice Address - Phone:360-386-8061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-19
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00004622282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital