Basic Information
| Provider Information | |||||||||
| NPI: | 1760117378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DON'T MIX | ||||||||
| FirstName: | HILARY | ||||||||
| MiddleName: | GWEN | ||||||||
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| Credential: | AAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2429 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986328486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605753316 | ||||||||
| FaxNumber: | 3604237813 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 FIR ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605753316 | ||||||||
| FaxNumber: | 3604237813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2022 | ||||||||
| LastUpdateDate: | 07/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | CG61315486 | WA | Y |
No ID Information.