MEDICARE: THE KETAMINE CLINIC OF SEATTLE. 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	363L00000X	Nurse Practitioner

General Provider Information

NPI Number	:	1730835042
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE KETAMINE CLINIC OF SEATTLE. LLC

Provider Business Mailing Address
First Line	:	3800 AURORA AVE N STE 360
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-8721
Country	:	US
Telephone Number	:	206-429-5029
Fax Number	:	206-504-2044

Provider Business Practice Location Address
First Line	:	3800 AURORA AVE N STE 360
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-8721
Country	:	US
Telephone Number	:	206-429-5029
Fax Number	:	206-504-2044

Authorized Official
Title or Position	:	ONWER
Name	:	DR. JULIE ANNE CHINNOCK
Credential	:	ARNP, CRNA, ND
Telephone Number	:	206-429-5029

Provider Enumeration Date	:	02/24/2022
Last Update Date	:	02/24/2022

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