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General NPI Number Information
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NPI Number | 1790460178
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Entity Type | Individual
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Provider Name | KOUASSI KAN BOUA LAZARE ASSIE NURSE PRACTITIONER
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Gender | Male
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Dates
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Enumeration Date | 06/21/2023
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Last Update Date | 04/15/2024
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Provider Practice Location Address
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Address Line | 13806 123RD AVE NE
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City | KIRKLAND
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State | WA
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Zip | 98034-2248
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Country | US
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Telephone | 206-384-2222
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Fax | 425-968-1999
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Provider Business Mailing Address
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Address Line | 1202 BERILLA DR
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City | ENUMCLAW
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State | WA
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Zip | 98022-8426
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Country | US
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Telephone | 206-384-2222
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Fax | 425-968-1999
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | AP61440338
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License Number State | WA
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