Healthcare Provider Details

I. General information

NPI: 1790936185
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES-WA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2008
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 PACIFIC AVE FIRST FLOOR
EVERETT WA
98201-4168
US

IV. Provider business mailing address

PO BOX 31001-4110
PASADENA CA
91110-4110
US

V. Phone/Fax

Practice location:
  • Phone: 425-258-7311
  • Fax: 425-258-7618
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License NumberHAC.FS.00000084
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DONALD WAYNE ANDERSON JR.
Title or Position: ASST SECRETARY-ENROLLMENT
Credential:
Phone: 425-358-9786