Basic Information
Provider Information | |||||||||
NPI: | 1871699090 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FITZPATRICK | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | FAITH | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.T. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FITZPATRICK | ||||||||
OtherFirstName: | LAURA | ||||||||
OtherMiddleName: | FAITH | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | P.T. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 11009 | ||||||||
Address2: |   | ||||||||
City: | OLYMPIA | ||||||||
State: | WA | ||||||||
PostalCode: | 985081009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3603522037 | ||||||||
FaxNumber: | 3604644851 | ||||||||
Practice Location | |||||||||
Address1: | 1175 CENTER DR | ||||||||
Address2: | SUITE 160 | ||||||||
City: | DUPONT | ||||||||
State: | WA | ||||||||
PostalCode: | 983277733 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2539641559 | ||||||||
FaxNumber: | 2539648495 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/15/2006 | ||||||||
LastUpdateDate: | 12/04/2009 | ||||||||
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 | 225100000X | 10736 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 226119 | 01 | WA | L & I | OTHER | 2586FI | 01 | WA | REGENCE | OTHER | 8496747 | 01 | WA | DSHS | OTHER |