Healthcare Provider Details

I. General information

NPI: 1447547658
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES-WA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14692 179TH AVE SE STE 800
MONROE WA
98272-1162
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 425-258-7550
  • Fax: 425-258-7450
Mailing address:
  • Phone: 425-316-5469
  • Fax: 425-316-5484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DONALD W ANDERSON JR.
Title or Position: DIR REIMB REG STRAT/ASST SEC ENROLL
Credential:
Phone: 425-358-9786