Healthcare Provider Details

I. General information

NPI: 1528637436
Provider Name (Legal Business Name): EVELYN LE ELLIS ND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1820 BLACK LAKE BLVD SW STE 101C
OLYMPIA WA
98512-5619
US

IV. Provider business mailing address

1820 BLACK LAKE BLVD SW STE 101C
OLYMPIA WA
98512-5619
US

V. Phone/Fax

Practice location:
  • Phone: 360-339-6169
  • Fax: 360-622-3366
Mailing address:
  • Phone: 360-339-6169
  • Fax: 360-622-3366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberNATU.NT.61193852
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNATU.NT.61193852
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberNATU.NT.61193852
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberNATU.NT.61193852
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberNATU.NT.61193852
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: