Basic Information
| Provider Information | |||||||||
| NPI: | 1306051867 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | JANET | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP, RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COSTANTINOU | ||||||||
| OtherFirstName: | JANET | ||||||||
| OtherMiddleName: | BLACK | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP, RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5040 STATE HIGHWAY 507 SE | ||||||||
| Address2: | |||||||||
| City: | TENINO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985899661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602645665 | ||||||||
| FaxNumber: | 3602645666 | ||||||||
| Practice Location | |||||||||
| Address1: | 273 SUSSEX AVE E | ||||||||
| Address2: | |||||||||
| City: | TENINO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985899359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602645665 | ||||||||
| FaxNumber: | 3602645666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 05/07/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP30004239 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.