Provider Demographics
NPI:1376650416
Name:PAVLOCK, CAROLYNN JEAN (DC)
Entity type:Individual
Prefix:DR
First Name:CAROLYNN
Middle Name:JEAN
Last Name:PAVLOCK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:CAROLYNN
Other - Middle Name:JEAN
Other - Last Name:PAVLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:17811 NE 20TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-9781
Mailing Address - Country:US
Mailing Address - Phone:360-989-6784
Mailing Address - Fax:
Practice Address - Street 1:17811 NE 20TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-9781
Practice Address - Country:US
Practice Address - Phone:360-989-6784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034560111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8871723Medicare PIN
WAU66248Medicare UPIN