Healthcare Provider Details

I. General information

NPI: 1730835042
Provider Name (Legal Business Name): THE KETAMINE CLINIC OF SEATTLE. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2022
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 AURORA AVE N STE 360
SEATTLE WA
98103-8721
US

IV. Provider business mailing address

3800 AURORA AVE N STE 360
SEATTLE WA
98103-8721
US

V. Phone/Fax

Practice location:
  • Phone: 206-429-5029
  • Fax: 206-504-2044
Mailing address:
  • Phone: 206-429-5029
  • Fax: 206-504-2044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. JULIE ANNE CHINNOCK
Title or Position: ONWER
Credential: ARNP, CRNA, ND
Phone: 206-429-5029