Healthcare Provider Details

I. General information

NPI: 1326340456
Provider Name (Legal Business Name): TABATHA BURRIS LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14410 PETROVISTSKY RD SE #109
RENTON WA
98058
US

IV. Provider business mailing address

17533 151ST AVENUE SE UNIT 8-9
RENTON WA
98058
US

V. Phone/Fax

Practice location:
  • Phone: 425-226-1856
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA60160181
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: