Provider Demographics
NPI:1811678519
Name:SMALLEY, LARRY VERN JR
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:VERN
Last Name:SMALLEY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25533
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98093-2533
Mailing Address - Country:US
Mailing Address - Phone:253-886-7762
Mailing Address - Fax:
Practice Address - Street 1:4526 FEDERAL AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2132
Practice Address - Country:US
Practice Address - Phone:425-349-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACM60901639374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician