Provider Demographics
NPI:1932740842
Name:EVERGREEN FAMILY PRACTICE, PLLC
Entity Type:Organization
Organization Name:EVERGREEN FAMILY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:360-438-3029
Mailing Address - Street 1:PO BOX 5807
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98509-5807
Mailing Address - Country:US
Mailing Address - Phone:360-438-3029
Mailing Address - Fax:360-438-8585
Practice Address - Street 1:205 LILLY RD NE STE A1
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5069
Practice Address - Country:US
Practice Address - Phone:360-438-3029
Practice Address - Fax:360-438-8585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty