Healthcare Provider Details

I. General information

NPI: 1174979710
Provider Name (Legal Business Name): SEASON FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 NE 7TH ST
RENTON WA
98056-3729
US

IV. Provider business mailing address

3201 NE 7TH ST
RENTON WA
98056-3729
US

V. Phone/Fax

Practice location:
  • Phone: 206-477-0100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60629286
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: