Provider Demographics
NPI:1912390527
Name:PERGRIM, AMANDA (LMP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:PERGRIM
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 1:12727 SE 318TH WAY
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98092-3672
Mailing Address - Country:US
Mailing Address - Phone:253-569-8215
Mailing Address - Fax:
Practice Address - Street 1:12727 SE 318TH WAY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98092-3672
Practice Address - Country:US
Practice Address - Phone:253-569-8215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-06
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60523826174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist