Healthcare Provider Details

I. General information

NPI: 1851083281
Provider Name (Legal Business Name): MARIENNE ALYSSA SANTA ELENA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23714 222ND PL SE STE B
MAPLE VALLEY WA
98038-5800
US

IV. Provider business mailing address

23714 222ND PL SE STE B
MAPLE VALLEY WA
98038-5800
US

V. Phone/Fax

Practice location:
  • Phone: 425-432-1206
  • Fax: 425-413-4465
Mailing address:
  • Phone: 425-432-1206
  • Fax: 425-413-4465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD61449531
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: