Provider Demographics
NPI:1043431539
Name:BOULDS-FISK, LAUREL A (LMP)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:A
Last Name:BOULDS-FISK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7030 121ST PL SE
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98056-1202
Mailing Address - Country:US
Mailing Address - Phone:425-687-6933
Mailing Address - Fax:425-687-6933
Practice Address - Street 1:1755 NE 48TH ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98056-9012
Practice Address - Country:US
Practice Address - Phone:206-679-4832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00007762174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist