Healthcare Provider Details

I. General information

NPI: 1619880739
Provider Name (Legal Business Name): WILDWOOD WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1523 132ND ST SE STE C-1028
EVERETT WA
98208-7200
US

IV. Provider business mailing address

2819 99TH PL SE
EVERETT WA
98208-2974
US

V. Phone/Fax

Practice location:
  • Phone: 425-332-8312
  • Fax:
Mailing address:
  • Phone: 843-442-9864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: DESIREE BALLESTEROS
Title or Position: ARNP
Credential: ARNP
Phone: 425-332-8312