Healthcare Provider Details

I. General information

NPI: 1528114394
Provider Name (Legal Business Name): AUDREY M.K. YAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 06/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24604 104TH AVE SE # 203
KENT WA
98030-4965
US

IV. Provider business mailing address

9620 S. 203RD STREET
KENT WA
98031
US

V. Phone/Fax

Practice location:
  • Phone: 253-859-2373
  • Fax: 253-856-8754
Mailing address:
  • Phone: 253-854-1823
  • Fax: 253-854-1823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA00005757
License Number StateWA

VIII. Authorized Official

Name: AUDREY M.K. YAN
Title or Position: OWNER
Credential: LMP
Phone: 253-854-1823