Healthcare Provider Details

I. General information

NPI: 1790760684
Provider Name (Legal Business Name): MS. GRACE G BALTAZAR
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 BROADWAY
SEATTLE WA
98122-3854
US

IV. Provider business mailing address

1527 14TH AVE S APT 202
SEATTLE WA
98144-7418
US

V. Phone/Fax

Practice location:
  • Phone: 206-726-3495
  • Fax: 206-726-3498
Mailing address:
  • Phone: 206-251-9184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberVA00040016
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: