Basic Information
| Provider Information | |||||||||
| NPI: | 1750729356 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUVER WENK | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARGARET | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 E MAIN ST | ||||||||
| Address2: | STE 100 | ||||||||
| City: | AUBURN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980024905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256903480 | ||||||||
| FaxNumber: | 4256909480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2013 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | AP60468077 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363L00000X | AP60468077 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2036415 | 05 | WA | MEDICAID |