Basic Information
| Provider Information | |||||||||
| NPI: | 1871685412 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE VALLE | ||||||||
| FirstName: | VIVIANE | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 N BROADWAY | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253170279 | ||||||||
| FaxNumber: | 4253170291 | ||||||||
| Practice Location | |||||||||
| Address1: | 12800 BOTHELL EVERETT HWY | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982086642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253165150 | ||||||||
| FaxNumber: | 4253165153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 02/24/2009 | ||||||||
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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 | 363A00000X | PA10000372 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8389918 | 05 | WA | MEDICAID |