Healthcare Provider Details

I. General information

NPI: 1548529837
Provider Name (Legal Business Name): LACEY M BLISS ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2012
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23213 PACIFIC HWY S
KENT WA
98032-2721
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 206-870-8880
  • Fax: 206-520-1499
Mailing address:
  • Phone: 206-543-6420
  • Fax: 206-520-5620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60277066
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60277066
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: