MEDICARE: PEACEFUL COEXISTENCE, LLC

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	:	1235747213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACEFUL COEXISTENCE, LLC

Provider Business Mailing Address
First Line	:	4730 UNIVERSITY WAY NE STE 104
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98105-4424
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4730 UNIVERSITY WAY NE STE 104
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98105-4424
Country	:	US
Telephone Number	:	206-627-0995
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LATOSHA DENT
Credential	:
Telephone Number	:	206-627-0995

Provider Enumeration Date	:	07/16/2020
Last Update Date	:	07/16/2020

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