MEDICARE: WESTERN WASHINGTON MEDICAL GROUP, INC PS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner

General Provider Information

NPI Number	:	1033853429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN WASHINGTON MEDICAL GROUP, INC PS

Provider Business Mailing Address
First Line	:	1728 W MARINE VIEW DR STE 110
Second Line	:
City	:	EVERETT
State	:	WA
Zip	:	98201-2094
Country	:	US
Telephone Number	:	425-259-4041
Fax Number	:

Provider Business Practice Location Address
First Line	:	1630 GROVE ST
Second Line	:
City	:	MARYSVILLE
State	:	WA
Zip	:	98270-4302
Country	:	US
Telephone Number	:	360-653-3500
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF PATIENT FINANCIAL SVCS
Name	:	AMELIA EDENS
Credential	:
Telephone Number	:	425-740-4142

Provider Enumeration Date	:	04/22/2022
Last Update Date	:	08/04/2023

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