Healthcare Provider Details

I. General information

NPI: 1154967099
Provider Name (Legal Business Name): BUPE MARTHA M HABIYAMBERE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 05/03/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 PACIFIC HWY E STE C2
FIFE WA
98424-2638
US

IV. Provider business mailing address

411 WALNUT ST PMP 20824
GREEN COVE SPRINGS FL
32043-3443
US

V. Phone/Fax

Practice location:
  • Phone: 425-381-6544
  • Fax: 425-285-7375
Mailing address:
  • Phone: 425-381-6544
  • Fax: 425-285-7375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61041972
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: