MEDICARE: CHRYSALIS PSYCHIATRY

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1104648732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRYSALIS PSYCHIATRY

Provider Business Mailing Address
First Line	:	PO BOX 1093
Second Line	:
City	:	PORT TOWNSEND
State	:	WA
Zip	:	98368-1093
Country	:	US
Telephone Number	:	206-279-4547
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 WATER ST # 1009
Second Line	:
City	:	PORT TOWNSEND
State	:	WA
Zip	:	98368-6705
Country	:	US
Telephone Number	:	206-279-4547
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANNE ELIZABETH KOOMEN
Credential	:	ARNP
Telephone Number	:	415-847-4643

Provider Enumeration Date	:	10/25/2024
Last Update Date	:	10/25/2024

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Directions to “CHRYSALIS PSYCHIATRY ” Practice Location

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