Healthcare Provider Details

I. General information

NPI: 1669220414
Provider Name (Legal Business Name): LEIF NESSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2024
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 MARTIN ST
BLAINE WA
98230-4045
US

IV. Provider business mailing address

1406 E REPUBLICAN ST APT 308
SEATTLE WA
98112-4788
US

V. Phone/Fax

Practice location:
  • Phone: 360-788-4228
  • Fax:
Mailing address:
  • Phone: 312-933-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: