Healthcare Provider Details

I. General information

NPI: 1295960219
Provider Name (Legal Business Name): ELIZABETH LANE HULALI WITHEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH LANE HULALI KENNEDY

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 SE EVERETT MALL WAY
EVERETT WA
98208-2833
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 425-347-5415
  • Fax: 425-347-2976
Mailing address:
  • Phone: 206-764-3335
  • Fax: 206-764-0489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberRC00040652
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: