Provider Demographics
NPI:1447885199
Name:PRIVITT, AMBER KAYLAN (SUDPT)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:KAYLAN
Last Name:PRIVITT
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13914 135TH STREET CT NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98329-5666
Mailing Address - Country:US
Mailing Address - Phone:253-509-4282
Mailing Address - Fax:
Practice Address - Street 1:729 PROSPECT ST STE 200
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-5330
Practice Address - Country:US
Practice Address - Phone:360-895-1307
Practice Address - Fax:360-895-4805
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60970695390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program