Healthcare Provider Details

I. General information

NPI: 1508609462
Provider Name (Legal Business Name): JOSHUA ICE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 NE 128TH ST STE 200
KIRKLAND WA
98034-7211
US

IV. Provider business mailing address

5517 113TH PL NE APT 73
KIRKLAND WA
98033-7548
US

V. Phone/Fax

Practice location:
  • Phone: 206-591-7245
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number61297157
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: