=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457492936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SNOQUALMIE VALLEY CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2007
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38700 SE RIVER ST
-----------------------------------------------------
City | SNOQUALMIE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98065-2013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-888-2299
-----------------------------------------------------
Fax | 425-888-1204
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2013
-----------------------------------------------------
City | SNOQUALMIE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98065-2013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-888-2299
-----------------------------------------------------
Fax | 425-888-1204
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC MANAGER
-----------------------------------------------------
Name | MS. SHERI MOKLEBUST
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 425-888-2299
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------