Healthcare Provider Details

I. General information

NPI: 1609357607
Provider Name (Legal Business Name): SALLY GRANTUSA BELLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 29TH ST SE
AUBURN WA
98002-7541
US

IV. Provider business mailing address

6400 SOUTHCENTER BLVD
TUKWILA WA
98188-2547
US

V. Phone/Fax

Practice location:
  • Phone: 253-876-7650
  • Fax: 253-876-7651
Mailing address:
  • Phone: 206-901-2000
  • Fax: 206-901-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN60468877
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: