Healthcare Provider Details

I. General information

NPI: 1578961769
Provider Name (Legal Business Name): ANDREA VALICOFF CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2014
Last Update Date: 08/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 43RD ST
RENTON WA
98055-5714
US

IV. Provider business mailing address

PO BOX 84571
SEATTLE WA
98124-5871
US

V. Phone/Fax

Practice location:
  • Phone: 800-540-1814
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN1026698
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60537170
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: