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General NPI Number Information
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NPI Number | 1083778104
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Entity Type | Individual
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Provider Name | MARIAM GEDEVANISHVILI
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Gender | Female
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Dates
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Enumeration Date | 12/21/2006
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Last Update Date | 06/11/2012
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Provider Practice Location Address
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Address Line | 10700 SE 208TH ST STE 207
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City | KENT
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State | WA
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Zip | 98031-5545
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Country | US
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Telephone | 206-755-1758
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Fax | 253-833-2686
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Provider Business Mailing Address
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Address Line | 18622 SE 265TH ST
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City | COVINGTON
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State | WA
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Zip | 98042-8421
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Country | US
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Telephone | 206-755-1758
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Fax | 253-883-2686
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133NN1002X
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Taxonomy Name | Nutrition Education Nutritionist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MA60058598
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License Number State | WA
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