Healthcare Provider Details

I. General information

NPI: 1861622557
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES - WA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 07/25/2025
Certification Date: 07/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 BOTHELL EVERETT HWY SUITE 110
EVERETT WA
98208-6642
US

IV. Provider business mailing address

PO BOX 34439
SEATTLE WA
98124-1439
US

V. Phone/Fax

Practice location:
  • Phone: 425-316-5140
  • Fax: 425-316-5141
Mailing address:
  • Phone: 425-316-5439
  • Fax: 425-316-5484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateWA

VIII. Authorized Official

Name: DONALD WAYNE ANDERSON JR.
Title or Position: ASSISTANT SECRETARY OF ENROLLMENTS
Credential:
Phone: 425-358-9786