Healthcare Provider Details

I. General information

NPI: 1669015939
Provider Name (Legal Business Name): BETHANY A WALLER ND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2019
Last Update Date: 10/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 N ALLEN PL
SEATTLE WA
98103-7412
US

IV. Provider business mailing address

1227 N ALLEN PL
SEATTLE WA
98103-7412
US

V. Phone/Fax

Practice location:
  • Phone: 206-624-6627
  • Fax: 206-525-5933
Mailing address:
  • Phone: 206-624-6627
  • Fax: 206-525-5933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNT60983754
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: