Healthcare Provider Details

I. General information

NPI: 1255736104
Provider Name (Legal Business Name): EDMONDS FAMILY MEDICINE CLINIC PS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7315 212TH ST SW SUITE 101
EDMONDS WA
98026-7610
US

IV. Provider business mailing address

7315 212TH ST SW SUITE 101
EDMONDS WA
98026-7610
US

V. Phone/Fax

Practice location:
  • Phone: 425-775-9474
  • Fax: 425-670-3554
Mailing address:
  • Phone: 425-775-9474
  • Fax: 425-670-3554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. MARCY SHIMADA
Title or Position: CEO
Credential:
Phone: 425-670-3555