Provider Demographics
NPI:1588164925
Name:NORTHWEST PEDIATRIC DERMATOLOGY, PLLC
Entity type:Organization
Organization Name:NORTHWEST PEDIATRIC DERMATOLOGY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOMBILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-539-6141
Mailing Address - Street 1:PO BOX 2314
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-2314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:703 LILLY RD NE STE 105
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5191
Practice Address - Country:US
Practice Address - Phone:360-539-6141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046225207N00000X, 207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty