Healthcare Provider Details

I. General information

NPI: 1366319824
Provider Name (Legal Business Name): GINA MARIE DEMMERLY LDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2025
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4854 RAINIER AVE S
SEATTLE WA
98118-1742
US

IV. Provider business mailing address

1125 E OLIVE ST APT 103
SEATTLE WA
98122-8406
US

V. Phone/Fax

Practice location:
  • Phone: 206-722-3939
  • Fax:
Mailing address:
  • Phone: 206-658-3786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDO60240657
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: