Healthcare Provider Details

I. General information

NPI: 1043705403
Provider Name (Legal Business Name): CAROLYN LOUISE VASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 11TH AVE NE STE 200
SEATTLE WA
98105-6367
US

IV. Provider business mailing address

658 SW MCCROHAN ST
OAK HARBOR WA
98277-4511
US

V. Phone/Fax

Practice location:
  • Phone: 206-616-4001
  • Fax:
Mailing address:
  • Phone: 360-929-6622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: