Healthcare Provider Details

I. General information

NPI: 1174581839
Provider Name (Legal Business Name): KRISTEN RAE GRUBB MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN RAE HAUGHT MD

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24493 CORNERSTONE
WESTLAKE OH
44145-4125
US

IV. Provider business mailing address

22100 BOTHELL EVERETT HWY
BOTHELL WA
98021-8431
US

V. Phone/Fax

Practice location:
  • Phone: 855-687-7237
  • Fax: 855-673-9190
Mailing address:
  • Phone: 855-687-7237
  • Fax: 855-687-7237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number044122
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: