Provider Demographics
NPI:1316007529
Name:SUFFERN-OSBURN, REVALLEE ANN (LMP)
Entity type:Individual
Prefix:MRS
First Name:REVALLEE
Middle Name:ANN
Last Name:SUFFERN-OSBURN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 LAURA DRIVE
Mailing Address - Street 2:
Mailing Address - City:CAMANO ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98282
Mailing Address - Country:US
Mailing Address - Phone:360-387-7390
Mailing Address - Fax:
Practice Address - Street 1:9522 271ST STREET NW
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292
Practice Address - Country:US
Practice Address - Phone:360-629-0800
Practice Address - Fax:360-629-6042
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019630174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0187950OtherLABOR & INDUSTRIES
WA163474OtherAMTA MEMBER