Provider Demographics
NPI:1992542096
Name:FOTHERINGILL, TY MICHAEL
Entity type:Individual
Prefix:
First Name:TY
Middle Name:MICHAEL
Last Name:FOTHERINGILL
Suffix:
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 1:1506 E RADIO RD
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-9589
Mailing Address - Country:US
Mailing Address - Phone:509-925-8497
Mailing Address - Fax:
Practice Address - Street 1:1506 E RADIO RD
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-9589
Practice Address - Country:US
Practice Address - Phone:509-925-8497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60315886163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse