Healthcare Provider Details

I. General information

NPI: 1700561891
Provider Name (Legal Business Name): CAITLIN STAVISH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2023
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4126 E MADISON ST STE 204
SEATTLE WA
98112-3345
US

IV. Provider business mailing address

1821 HARVARD AVE APT 303
SEATTLE WA
98122-2212
US

V. Phone/Fax

Practice location:
  • Phone: 206-926-9901
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMC61359162
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: