Provider Demographics
NPI:1114636669
Name:RAINIER VALLEY WELLNESS
Entity type:Organization
Organization Name:RAINIER VALLEY WELLNESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:KALEILANI
Authorized Official - Last Name:LAWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MS RN
Authorized Official - Phone:206-474-6267
Mailing Address - Street 1:4704 S MEAD ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-2810
Mailing Address - Country:US
Mailing Address - Phone:206-474-6267
Mailing Address - Fax:
Practice Address - Street 1:4708 S MEAD ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-2810
Practice Address - Country:US
Practice Address - Phone:206-474-6267
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RAINIER VALLEY COMMUNITY CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-22
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty