Basic Information
| Provider Information | |||||||||
| NPI: | 1154635464 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NAKAYAMA | ||||||||
| FirstName: | AI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAKADO | ||||||||
| OtherFirstName: | AI | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3717 NW 12TH AVE | ||||||||
| Address2: | |||||||||
| City: | CAMAS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986077985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4259316098 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 801 SE PARK CREST AVENUE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602602200 | ||||||||
| FaxNumber: | 3103231570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2010 | ||||||||
| LastUpdateDate: | 08/21/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 225X00000X | 60206072 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.