Healthcare Provider Details

I. General information

NPI: 1154893311
Provider Name (Legal Business Name): HEIDI L KNICKERBOCKER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2018
Last Update Date: 12/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 3RD AVE
SEATTLE WA
98104-3282
US

IV. Provider business mailing address

509 3RD AVE
SEATTLE WA
98104-3282
US

V. Phone/Fax

Practice location:
  • Phone: 206-464-1570
  • Fax:
Mailing address:
  • Phone: 206-464-1570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN60478116
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: