Healthcare Provider Details

I. General information

NPI: 1790801801
Provider Name (Legal Business Name): PROVIDENCE AUDIOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E JEFFERSON ST SUITE 202
SEATTLE WA
98122-5698
US

IV. Provider business mailing address

1600 E JEFFERSON ST SUITE 202
SEATTLE WA
98122-5698
US

V. Phone/Fax

Practice location:
  • Phone: 206-320-5687
  • Fax: 206-320-8145
Mailing address:
  • Phone: 206-320-5687
  • Fax: 206-320-8145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberLD00001067
License Number StateWA

VIII. Authorized Official

Name: SANDRA ELLIS
Title or Position: OWNER
Credential: AU.D., FAAA
Phone: 206-320-5687