Healthcare Provider Details

I. General information

NPI: 1801495890
Provider Name (Legal Business Name): JULEAH R. RUSSEK TABAK ND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11521 SE 259TH ST # 102
KENT WA
98030-7856
US

IV. Provider business mailing address

11521 SE 259TH ST UNIT 102
KENT WA
98030-7856
US

V. Phone/Fax

Practice location:
  • Phone: 425-577-9414
  • Fax:
Mailing address:
  • Phone: 425-577-9414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNT61092851
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: