MEDICARE: MELYNDA B ELBENNANE PTA

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	174400000X	Specialist

General Provider Information

NPI Number	:	1730397746
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELYNDA B ELBENNANE PTA

Provider Business Mailing Address
First Line	:	17641 156TH AVE SE
Second Line	:
City	:	RENTON
State	:	WA
Zip	:	98058-9011
Country	:	US
Telephone Number	:	206-898-1857
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 ANDOVER PARK E
Second Line	:	SUITE 6
City	:	TUKWILA
State	:	WA
Zip	:	98188-2938
Country	:	US
Telephone Number	:	206-575-3182
Fax Number	:

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	08/16/2010

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