MEDICARE: MARIAM GEDEVANISHVILI

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	133NN1002X	Nutrition Education Nutritionist
2	2255A2300X	Athletic Trainer
3	225700000X	Massage Therapist	MA60058598	WA

General Provider Information

NPI Number	:	1083778104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAM GEDEVANISHVILI

Provider Business Mailing Address
First Line	:	18622 SE 265TH ST
Second Line	:
City	:	COVINGTON
State	:	WA
Zip	:	98042-8421
Country	:	US
Telephone Number	:	206-755-1758
Fax Number	:	253-883-2686

Provider Business Practice Location Address
First Line	:	10700 SE 208TH ST STE 207
Second Line	:
City	:	KENT
State	:	WA
Zip	:	98031-5545
Country	:	US
Telephone Number	:	206-755-1758
Fax Number	:	253-833-2686

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	06/11/2012

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