Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | AP60698848 | WA |
NPI | 1003263872 |
---|---|
Provider Name | Laura Ely |
First Address | Othello, WA 99344-1846 |
Second Address | Othello, WA 99344-1846 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2016 |
Last Update Date | 17/02/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2068095 | (05) | WA |