Basic Information
| Provider Information | |||||||||
| NPI: | 1578614830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARTER | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1148 BROADWAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984023518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535974550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1148 BROADWAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984023518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535974550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP30006831 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | US7189649 | 01 | WA | AETNA SPECIALIST PIN | OTHER | 8807CA | 01 | WA | BLUE SHIELD # | OTHER | 0039590 | 01 | WA | LABOR AND INDUSTRIES # | OTHER | 9644071 | 05 | WA | MEDICAID |