Healthcare Provider Details

I. General information

NPI: 1881532224
Provider Name (Legal Business Name): ELYSE RENE SMYLIE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELYSE RENE LEWAN PTA

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18323 98TH AVE NE STE 1
BOTHELL WA
98011-3358
US

IV. Provider business mailing address

18323 98TH AVE NE STE 1
BOTHELL WA
98011-3358
US

V. Phone/Fax

Practice location:
  • Phone: 618-779-1695
  • Fax: 425-371-7071
Mailing address:
  • Phone: 618-779-1695
  • Fax: 425-371-7071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA.P1.61399473
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: