Provider Demographics
NPI:1790760684
Name:BALTAZAR, GRACE G
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:G
Last Name:BALTAZAR
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 1:1527 14TH AVE S
Mailing Address - Street 2:APT 202
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-7418
Mailing Address - Country:US
Mailing Address - Phone:206-251-9184
Mailing Address - Fax:
Practice Address - Street 1:1407 BROADWAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-3854
Practice Address - Country:US
Practice Address - Phone:206-726-3495
Practice Address - Fax:206-726-3498
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00040016183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician