Provider Demographics
NPI:1679691505
Name:OUELLETTE, TODD R (ARNP)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:R
Last Name:OUELLETTE
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2101 LITTLE MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-8752
Mailing Address - Country:US
Mailing Address - Phone:360-428-2622
Mailing Address - Fax:360-428-3941
Practice Address - Street 1:2101 LITTLE MOUNTAIN LN
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-8752
Practice Address - Country:US
Practice Address - Phone:360-428-2622
Practice Address - Fax:360-428-3941
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30002202363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9620253Medicaid