Provider Demographics
NPI:1376509174
Name:DESYATNIKOVA, STELLA (MD)
Entity Type:Individual
Prefix:DR
First Name:STELLA
Middle Name:
Last Name:DESYATNIKOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 OLIVE WAY
Mailing Address - Street 2:SUITE 1430
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1720
Mailing Address - Country:US
Mailing Address - Phone:206-682-3223
Mailing Address - Fax:
Practice Address - Street 1:509 OLIVE WAY
Practice Address - Street 2:SUITE 1430
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1720
Practice Address - Country:US
Practice Address - Phone:206-682-3223
Practice Address - Fax:206-682-3224
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD0041231207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAH67781Medicare UPIN
WA8803915Medicare ID - Type Unspecified