Provider Demographics
NPI:1609673078
Name:WHITAKER, IMARA NYERE
Entity type:Individual
Prefix:
First Name:IMARA
Middle Name:NYERE
Last Name:WHITAKER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 MAC LN SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98513-7742
Mailing Address - Country:US
Mailing Address - Phone:360-842-6217
Mailing Address - Fax:
Practice Address - Street 1:402 YAUGER WAY SW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8660
Practice Address - Country:US
Practice Address - Phone:360-878-8248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist