Basic Information
| Provider Information | |||||||||
| NPI: | 1861994675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAZZONE | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 N IRON BRIDGE WAY | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992024932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094448888 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5901 N LIDGERWOOD ST STE 223 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992081122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094448200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2018 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P2201X | PH60780614 | WA | N | 183500000X | PH60780614 | WA | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | PH60780614 | 01 | WA | WASHINGTON STATE PHARMACY QUALITY ASSURANCE COMMISSION | OTHER |