Healthcare Provider Details

I. General information

NPI: 1386557619
Provider Name (Legal Business Name): ICE'SHAY ASHANTI PENNEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2026
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15117 MAIN ST STE 205
MILL CREEK WA
98012-9035
US

IV. Provider business mailing address

15117 MAIN ST STE 205
MILL CREEK WA
98012-9035
US

V. Phone/Fax

Practice location:
  • Phone: 425-474-0162
  • Fax: 425-944-7950
Mailing address:
  • Phone: 425-474-0162
  • Fax: 425-944-7950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: