Healthcare Provider Details

I. General information

NPI: 1467890277
Provider Name (Legal Business Name): SARAH TYACK RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3670 169TH AVE NE
BELLEVUE WA
98008-6142
US

IV. Provider business mailing address

1824 MARKET ST
KIRKLAND WA
98033-4946
US

V. Phone/Fax

Practice location:
  • Phone: 206-601-2976
  • Fax:
Mailing address:
  • Phone: 206-601-2976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN 00110305
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: