Provider Demographics
NPI:1861622557
Name:PROVIDENCE HEALTH & SERVICES - WA
Entity type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES - WA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR RCM NWR PHYSICIAN DIVISION
Authorized Official - Prefix:
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-317-0284
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:425-316-5439
Mailing Address - Fax:425-316-5484
Practice Address - Street 1:12800 BOTHELL EVERETT HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-6642
Practice Address - Country:US
Practice Address - Phone:425-316-5140
Practice Address - Fax:425-316-5141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-16
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA104100000X, 133V00000X, 163W00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8877705Medicare PIN