Healthcare Provider Details

I. General information

NPI: 1023284122
Provider Name (Legal Business Name): WALLINGFORD PEDIATRICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 WALLINGFORD AVE N
SEATTLE WA
98103-8218
US

IV. Provider business mailing address

PO BOX 31509
SEATTLE WA
98103
US

V. Phone/Fax

Practice location:
  • Phone: 206-632-0542
  • Fax:
Mailing address:
  • Phone: 206-632-0542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberMD00012418
License Number StateWA

VIII. Authorized Official

Name: DEBORAH C NIEBLA
Title or Position: OFFICE MANAGER
Credential:
Phone: 206-632-0542