Healthcare Provider Details

I. General information

NPI: 1891652913
Provider Name (Legal Business Name): NICOLE SIRIVANSANTI LAC, EAMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2026
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 S ORCAS ST # 205
SEATTLE WA
98108-2652
US

IV. Provider business mailing address

7701 RENTON AVE S
SEATTLE WA
98118-4134
US

V. Phone/Fax

Practice location:
  • Phone: 701-404-7977
  • Fax:
Mailing address:
  • Phone: 701-404-7977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC70065208
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: