Provider Demographics
NPI:1922026178
Name:HARRIS, THERESA J (ARNP)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:J
Last Name:HARRIS
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 1:1706 S MERIDIAN STE 130
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-7516
Mailing Address - Country:US
Mailing Address - Phone:253-848-8797
Mailing Address - Fax:253-845-1114
Practice Address - Street 1:1706 S MERIDIAN STE 130
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-7516
Practice Address - Country:US
Practice Address - Phone:253-848-8797
Practice Address - Fax:253-845-1114
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006868363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4307205Medicaid
WA9647132Medicaid
ID807332000Medicaid
MT4307205Medicaid
MT4307205Medicaid