Basic Information
| Provider Information | |||||||||
| NPI: | 1063907350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHERRY | ||||||||
| FirstName: | BRENNA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12025 131ST LN NE APT E200 | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980348074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098322129 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13010 NE 20TH ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980052054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256446328 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2018 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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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 | 106S00000X | WA | Y |
No ID Information.