Healthcare Provider Details

I. General information

NPI: 1407268857
Provider Name (Legal Business Name): LAUREN KATHLEEN FETTY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

939 CAROLINE ST
PORT ANGELES WA
98362-3909
US

IV. Provider business mailing address

19020 33RD AVE W STE 210
LYNNWOOD WA
98036-4748
US

V. Phone/Fax

Practice location:
  • Phone: 360-565-9003
  • Fax: 360-565-9001
Mailing address:
  • Phone: 425-563-1500
  • Fax: 425-563-1374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number71514-20
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD61038016
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: