Healthcare Provider Details

I. General information

NPI: 1306996707
Provider Name (Legal Business Name): MARIE WITHERELL RN IBCLC ICCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 NW 70TH ST
SEATTLE WA
98117-5340
US

IV. Provider business mailing address

2253 NW 61ST ST UNIT C
SEATTLE WA
98107-5417
US

V. Phone/Fax

Practice location:
  • Phone: 206-781-9871
  • Fax:
Mailing address:
  • Phone: 206-781-9637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN00112713
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: