Healthcare Provider Details

I. General information

NPI: 1669553251
Provider Name (Legal Business Name): EASTSIDE WOMENS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 10/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11919 NE 128TH ST SUITE C
KIRKLAND WA
98034-7204
US

IV. Provider business mailing address

11919 NE 128TH ST SUITE C
KIRKLAND WA
98034-7204
US

V. Phone/Fax

Practice location:
  • Phone: 425-899-5600
  • Fax: 425-899-5603
Mailing address:
  • Phone: 425-899-5600
  • Fax: 425-899-5603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number601368747
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberAP 30000483
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberAP 30000483
License Number StateWA

VIII. Authorized Official

Name: SUZAN JEANNE WATANABE
Title or Position: OWNER
Credential: ARNP
Phone: 425-899-5600