Healthcare Provider Details

I. General information

NPI: 1073978565
Provider Name (Legal Business Name): BROOKE ERICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2015
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11636 SE 5TH ST STE 100
BELLEVUE WA
98005-3527
US

IV. Provider business mailing address

1420 NW GILMAN BLVD # 2237
ISSAQUAH WA
98027-5394
US

V. Phone/Fax

Practice location:
  • Phone: 425-395-4638
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number603550453
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: