Healthcare Provider Details

I. General information

NPI: 1861577223
Provider Name (Legal Business Name): ELLENDEE PEPPER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 SW 39TH ST STE 150
RENTON WA
98057-4912
US

IV. Provider business mailing address

PO BOX 34876
SEATTLE WA
98124-1876
US

V. Phone/Fax

Practice location:
  • Phone: 425-793-4700
  • Fax: 425-656-4046
Mailing address:
  • Phone: 425-228-3440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD00022801
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: