Healthcare Provider Details

I. General information

NPI: 1861715096
Provider Name (Legal Business Name): JENNIFER KELLY BURZAWA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 TALBOT RD S STE 300
RENTON WA
98055-5738
US

IV. Provider business mailing address

3600 LIND AVE SW SUITE 100 ATTN CREDENTIALING
RENTON WA
98057-4970
US

V. Phone/Fax

Practice location:
  • Phone: 425-690-3409
  • Fax: 425-690-9004
Mailing address:
  • Phone: 425-690-2715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD60908012
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberN3525
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberMD60908012
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: