Healthcare Provider Details

I. General information

NPI: 1740588995
Provider Name (Legal Business Name): AUTUMN JOY GRIFFIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 10/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12911 120TH AVE NE # 10
KIRKLAND WA
98034-3027
US

IV. Provider business mailing address

7255 115TH PL SE
NEWCASTLE WA
98056-4302
US

V. Phone/Fax

Practice location:
  • Phone: 425-821-9833
  • Fax: 425-821-9443
Mailing address:
  • Phone: 603-339-2934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60303059
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: