Provider Demographics
NPI:1275110041
Name:ELLINGSEN, TAYLOR ANNE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ANNE
Last Name:ELLINGSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 NE PACIFIC ST BOX 357134
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-0001
Mailing Address - Country:US
Mailing Address - Phone:509-389-5567
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:425-954-6797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61163825204E00000X
390200000X
WA61219793122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program