Healthcare Provider Details

I. General information

NPI: 1083778104
Provider Name (Legal Business Name): MARIAM GEDEVANISHVILI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 SE 208TH ST STE 207
KENT WA
98031-5545
US

IV. Provider business mailing address

18622 SE 265TH ST
COVINGTON WA
98042-8421
US

V. Phone/Fax

Practice location:
  • Phone: 206-755-1758
  • Fax: 253-833-2686
Mailing address:
  • Phone: 206-755-1758
  • Fax: 253-883-2686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60058598
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: