MEDICARE: SUZANNE ANNETTE MCDONOUGH LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MA00020985	WA

General Provider Information

NPI Number	:	1629307939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUZANNE ANNETTE MCDONOUGH LMP

Provider Business Mailing Address
First Line	:	5400 CALIFORNIA AVE SW
Second Line	:	SUITE F
City	:	SEATTLE
State	:	WA
Zip	:	98136-1501
Country	:	US
Telephone Number	:	206-937-8866
Fax Number	:	206-937-8869

Provider Business Practice Location Address
First Line	:	5400 CALIFORNIA AVE SW
Second Line	:	SUITE F
City	:	SEATTLE
State	:	WA
Zip	:	98136-1501
Country	:	US
Telephone Number	:	206-937-8866
Fax Number	:	206-937-8869

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2009
Last Update Date	:	12/15/2009

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