Healthcare Provider Details

I. General information

NPI: 1104530526
Provider Name (Legal Business Name): CLYSTA COLE CPSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2023
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 24TH AVE S
SEATTLE WA
98144-4637
US

IV. Provider business mailing address

PO BOX 2429
LONGVIEW WA
98632-8486
US

V. Phone/Fax

Practice location:
  • Phone: 206-382-5340
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number70074097
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: