Healthcare Provider Details

I. General information

NPI: 1033846332
Provider Name (Legal Business Name): KELLY ANNE MEDZEGIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2022
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18311 BOTHELL EVERETT HWY STE 260
BOTHELL WA
98012-5233
US

IV. Provider business mailing address

954 88TH AVE NE
MEDINA WA
98039-4831
US

V. Phone/Fax

Practice location:
  • Phone: 425-518-5253
  • Fax:
Mailing address:
  • Phone: 425-518-5253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: