Basic Information
| Provider Information | |||||||||
| NPI: | 1053743716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLETTE | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 12TH AVE S | ||||||||
| Address2: | SUITE 901 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981442712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065483114 | ||||||||
| FaxNumber: | 2067626355 | ||||||||
| Practice Location | |||||||||
| Address1: | 24215 PACIFIC HWY S | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981984024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064366380 | ||||||||
| FaxNumber: | 2064366385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2013 | ||||||||
| LastUpdateDate: | 01/27/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP60387105 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.