Basic Information
| Provider Information | |||||||||
| NPI: | 1649298787 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | NAN | ||||||||
| MiddleName: | VICTORIA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE | ||||||||
| Address2: | SUITA 100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908004317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624996191 | ||||||||
| FaxNumber: | 5624996171 | ||||||||
| Practice Location | |||||||||
| Address1: | 3322 BROADWAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982012777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252494841 | ||||||||
| FaxNumber: | 4253398283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/18/2013 | ||||||||
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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 | 163W00000X | RN00103948 | WA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | AP30002220 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 9607128 | 05 | WA | MEDICAID | 0155908 | 01 | WA | LABOR & INDUSTRY | OTHER | 1015416 | 01 | WA | PROVIDERONE ID | OTHER | 55198U | 01 | WA | REGENCE BLUESHIELD | OTHER |