Basic Information
| Provider Information | |||||||||
| NPI: | 1881212249 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANCEL | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | PERSEPHONE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4446 S 160TH ST | ||||||||
| Address2: | |||||||||
| City: | TUKWILA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981882755 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1210 SW 136TH ST | ||||||||
| Address2: | |||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981661214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062576600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2020 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.