Healthcare Provider Details

I. General information

NPI: 1891416145
Provider Name (Legal Business Name): MABEL EZEONWU ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2022
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18115 CAMPUS WAY NE
BOTHELL WA
98011-8246
US

IV. Provider business mailing address

18115 CAMPUS WAY NE
BOTHELL WA
98011-8246
US

V. Phone/Fax

Practice location:
  • Phone: 425-352-3815
  • Fax:
Mailing address:
  • Phone: 425-352-3815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61351676
License Number StateWA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: