Basic Information
Provider Information | |||||||||
NPI: | 1578537205 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REESE | ||||||||
FirstName: | CYNTHIA | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | B.A., M.S.N. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BEATTY | ||||||||
OtherFirstName: | CYNTHIA | ||||||||
OtherMiddleName: | F | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 55 W TIETAN ST | ||||||||
Address2: |   | ||||||||
City: | WALLA WALLA | ||||||||
State: | WA | ||||||||
PostalCode: | 993624445 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5095253720 | ||||||||
FaxNumber: | 5095221592 | ||||||||
Practice Location | |||||||||
Address1: | 320 W WILLOW ST | ||||||||
Address2: |   | ||||||||
City: | WALLA WALLA | ||||||||
State: | WA | ||||||||
PostalCode: | 993622922 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5095255010 | ||||||||
FaxNumber: | 5095229448 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/17/2006 | ||||||||
LastUpdateDate: | 01/15/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | AP30003228 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 165697 | 05 | WA |   | MEDICAID | 9610056 | 05 | WA |   | MEDICAID |