Provider Demographics
NPI:1124453790
Name:HARRISON, SUSAN CANDICE (AC60279069)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:CANDICE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:AC60279069
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7056 PORTAL WAY # R7
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-8310
Mailing Address - Country:US
Mailing Address - Phone:360-366-4216
Mailing Address - Fax:360-366-4241
Practice Address - Street 1:7056 PORTAL WAY # R7
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-8310
Practice Address - Country:US
Practice Address - Phone:360-366-4216
Practice Address - Fax:360-366-4241
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60279069171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAEIN# 30-0793032OtherUBI# 603-318-082