Provider Demographics
NPI:1245852524
Name:CISCO, LUTRICIA LEVETTE (RN)
Entity type:Individual
Prefix:
First Name:LUTRICIA
Middle Name:LEVETTE
Last Name:CISCO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LUTRICIA
Other - Middle Name:L
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:1617 FONES RD SE TRLR 35
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-7408
Mailing Address - Country:US
Mailing Address - Phone:360-999-1910
Mailing Address - Fax:360-459-3705
Practice Address - Street 1:400 UNION AVE SE STE 244
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-2060
Practice Address - Country:US
Practice Address - Phone:360-918-7240
Practice Address - Fax:360-459-3705
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-10
Last Update Date:2020-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60086332163WP0808X
WA101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health