Healthcare Provider Details

I. General information

NPI: 1477882108
Provider Name (Legal Business Name): NICOLE MARIE DONOVAN LM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13128 TOTEM LAKE BLVD NE STE 101
KIRKLAND WA
98034-2953
US

IV. Provider business mailing address

20115 75TH AVE NE
KENMORE WA
98028-2012
US

V. Phone/Fax

Practice location:
  • Phone: 425-823-1919
  • Fax:
Mailing address:
  • Phone: 206-478-1771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMW 60066915
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: