Healthcare Provider Details

I. General information

NPI: 1063184679
Provider Name (Legal Business Name): EXTRAORDINARY WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21410 1ST AVE W UNIT B
BOTHELL WA
98021-7514
US

IV. Provider business mailing address

21410 1ST AVE W UNIT B
BOTHELL WA
98021-7514
US

V. Phone/Fax

Practice location:
  • Phone: 928-303-1593
  • Fax:
Mailing address:
  • Phone: 928-303-1593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MARISSA S BOYD
Title or Position: OWNER, MANAGING MEMBER
Credential: ND
Phone: 928-303-1593