Healthcare Provider Details

I. General information

NPI: 1952833683
Provider Name (Legal Business Name): ELLYSE RENEE RENGSTORF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19245 7TH AVE NE
POULSBO WA
98370-6551
US

IV. Provider business mailing address

9621 RIDGETOP BLVD NW
SILVERDALE WA
98383-8502
US

V. Phone/Fax

Practice location:
  • Phone: 360-782-3501
  • Fax: 360-782-3540
Mailing address:
  • Phone: 360-782-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD61074527
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: