Provider Demographics
NPI:1912606237
Name:THE SWEET LIFE ADVANCED DIABETES MANAGEMENT LLC
Entity Type:Organization
Organization Name:THE SWEET LIFE ADVANCED DIABETES MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN,NP,AANP
Authorized Official - Phone:808-772-3715
Mailing Address - Street 1:4110 61ST CT SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-7043
Mailing Address - Country:US
Mailing Address - Phone:808-772-3715
Mailing Address - Fax:
Practice Address - Street 1:4110 61ST CT SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7043
Practice Address - Country:US
Practice Address - Phone:808-772-3715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-24
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60328811OtherRN
WAF10180045OtherAANP
WA60909311OtherNP