Basic Information
| Provider Information | |||||||||
| NPI: | 1568905107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SEXTON | ||||||||
| FirstName: | DTAWAHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DNP, FNP-BC, RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 S KITSAP BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983663773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608745900 | ||||||||
| FaxNumber: | 2539526824 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 S KITSAP BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ORCHARD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983663773 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608745900 | ||||||||
| FaxNumber: | 2539526824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2016 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN216522 | GA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 2016024386 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP60863630 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2104738 | 05 | WA | MEDICAID |