Provider Demographics
NPI:1780805507
Name:LAWRENCE, TRISTA RAWLINGS (LMP)
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:RAWLINGS
Last Name:LAWRENCE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:TRISTA
Other - Middle Name:
Other - Last Name:RAWLINGS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:PO BOX 2647
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98231
Mailing Address - Country:US
Mailing Address - Phone:360-332-8000
Mailing Address - Fax:360-371-4085
Practice Address - Street 1:477 PEACE PORTAL DRIVE
Practice Address - Street 2:SUITE 5B
Practice Address - City:BLAINE
Practice Address - State:WA
Practice Address - Zip Code:98230
Practice Address - Country:US
Practice Address - Phone:360-332-8000
Practice Address - Fax:360-371-4085
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012980174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA140125OtherL&I PROVIDER #
WA1236RAOtherADDITIONAL RBS PROVIDER N
WA1714RAOtherRBS PROVIDER NUMBER