Healthcare Provider Details

I. General information

NPI: 1295751170
Provider Name (Legal Business Name): LICIA LYNN RAYMOND MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 NE BLAKELY DR STE 2030
ISSAQUAH WA
98029-6201
US

IV. Provider business mailing address

PO BOX 25608
SALT LAKE CITY UT
84125-0608
US

V. Phone/Fax

Practice location:
  • Phone: 425-313-7080
  • Fax: 425-313-7071
Mailing address:
  • Phone: 206-320-4476
  • Fax: 206-568-7643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD60660120
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number238127
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number4301055550
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: