Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DN361 | WA |
NPI | 1679675367 |
---|---|
Provider Name | Ms. Maenell Sullivan |
First Address | Tenino, WA 98589 |
Second Address | Tenino, WA 98589 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5045273 | DSHS (01) | WA |