Provider Demographics
NPI:1689609463
Name:MAIN, CAROLYN C (ARNP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:C
Last Name:MAIN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 1ST AVE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-1123
Mailing Address - Country:US
Mailing Address - Phone:206-448-2516
Mailing Address - Fax:206-448-6473
Practice Address - Street 1:1414 116TH AVE NE
Practice Address - Street 2:SUITE E
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3801
Practice Address - Country:US
Practice Address - Phone:206-215-4545
Practice Address - Fax:206-215-4550
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003567363L00000X
WARN00053407363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0194898OtherL & I
WA9620600Medicaid
WA0194898OtherL & I
WAS45356Medicare UPIN