Provider Demographics
NPI:1285865402
Name:WILTERMUTH, BRANDY LEE (AP)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:LEE
Last Name:WILTERMUTH
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19930 BALLINGER WAY NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-1223
Mailing Address - Country:US
Mailing Address - Phone:425-778-2220
Mailing Address - Fax:
Practice Address - Street 1:17924 140TH AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-4315
Practice Address - Country:US
Practice Address - Phone:425-778-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60226772363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42536529Medicaid
WAAP60226772OtherMEDICAL LICENSE
WAAP60226772OtherMEDICAL LICENSE