=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619023827
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMY LEE SANGDER LMP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3710 168TH ST NE SUITE #B201
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98223-8416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-737-5812
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11901 55TH AVE NE #2
-----------------------------------------------------
City | MARYSVILLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98271-8542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-653-9027
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MA00021168
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------