Basic Information
| Provider Information | |||||||||
| NPI: | 1255843041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ST-MARTIN | ||||||||
| FirstName: | GENEVIEVE | ||||||||
| MiddleName: | NICOLE CANNING | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1003 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534032313 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1003 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534031677 | ||||||||
| FaxNumber: | 2534031676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2017 | ||||||||
| LastUpdateDate: | 02/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | 60802773 | WA | Y | Other Service Providers | Genetic Counselor, MS |
ID Information
| ID | Type | State | Issuer | Description | 60802773 | 01 | WA | GENETIC COUNSELOR PROVISIONAL LICENSE | OTHER |