Healthcare Provider Details

I. General information

NPI: 1164451142
Provider Name (Legal Business Name): STILLAGUAMISH TRIBAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24205 JAMES DORSEY WAY STE 1
ARLINGTON WA
98223-6029
US

IV. Provider business mailing address

24205 JAMES DORSEY WAY STE 1
ARLINGTON WA
98223-6029
US

V. Phone/Fax

Practice location:
  • Phone: 360-435-9338
  • Fax: 360-435-2266
Mailing address:
  • Phone: 360-435-9338
  • Fax: 360-435-2266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberAP30001255
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberAP30001255
License Number StateWA

VIII. Authorized Official

Name: DANNIELLE MARIE HANCOCK
Title or Position: ACCOUNT MANAGER
Credential:
Phone: 360-631-5971