Basic Information
| Provider Information | |||||||||
| NPI: | 1598358657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRAWITZ | ||||||||
| FirstName: | KEELY | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2080 N TUSTIN AVE STE B | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927057875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555810100 | ||||||||
| FaxNumber: | 8553293973 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 15TH AVE SW STE A | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983717873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555810100 | ||||||||
| FaxNumber: | 8553293973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2021 | ||||||||
| LastUpdateDate: | 02/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.