Healthcare Provider Details

I. General information

NPI: 1770086431
Provider Name (Legal Business Name): AISLINN WYATT LCPO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 S COLUMBIAN WAY PROSTHETICS 663/S-121 PSAS
SEATTLE WA
98108
US

IV. Provider business mailing address

3421 40TH AVE W
SEATTLE WA
98199-1922
US

V. Phone/Fax

Practice location:
  • Phone: 206-277-6809
  • Fax:
Mailing address:
  • Phone: 206-285-3065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberOI.60810115
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPS60912047
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: