Provider Demographics
NPI:1942274204
Name:PRIDEAUX BLODGETT, BECKY JEAN (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:BECKY
Middle Name:JEAN
Last Name:PRIDEAUX BLODGETT
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:JEAN
Other - Last Name:BLODGETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:7808 PACIFIC AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-7039
Mailing Address - Country:US
Mailing Address - Phone:253-503-6178
Mailing Address - Fax:253-240-0587
Practice Address - Street 1:7808 PACIFIC AVE STE 3
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7039
Practice Address - Country:US
Practice Address - Phone:253-503-6178
Practice Address - Fax:253-240-0587
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00089325363L00000X
WAAP30003968363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP30003968OtherLICENSE
WARN00089325OtherLICENSE
WACO3401OtherMEDICARE OTHER-GROUP
WA500004687OtherMEDICARE OTHER-INDIVIDUAL
WAAP30003968OtherLICENSE
WACO3401OtherMEDICARE OTHER-GROUP