Healthcare Provider Details

I. General information

NPI: 1922573484
Provider Name (Legal Business Name): LISA SUSAN EARLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 SW 136TH ST
BURIEN WA
98166-1214
US

IV. Provider business mailing address

1210 SW 136TH ST
BURIEN WA
98166-1214
US

V. Phone/Fax

Practice location:
  • Phone: 206-257-6601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: