Healthcare Provider Details

I. General information

NPI: 1780814830
Provider Name (Legal Business Name): GELEA NICHOLE ICE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9720 4TH AVE NE
SEATTLE WA
98115-2143
US

IV. Provider business mailing address

9720 4TH AVE NE
SEATTLE WA
98115-2143
US

V. Phone/Fax

Practice location:
  • Phone: 206-527-7132
  • Fax:
Mailing address:
  • Phone: 206-527-7132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number664
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: