Healthcare Provider Details

I. General information

NPI: 1699737395
Provider Name (Legal Business Name): JEUDIEL R. PUENTE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST
SEATTLE WA
98195-0001
US

IV. Provider business mailing address

26323 NE 25TH ST
REDMOND WA
98053-9081
US

V. Phone/Fax

Practice location:
  • Phone: 206-598-4260
  • Fax: 206-598-8812
Mailing address:
  • Phone: 425-213-9915
  • Fax: 425-898-7105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN00156597
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30006800
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: