Provider Demographics
NPI:1851549034
Name:VILLAGE FAMILY CLINIC AND WELLNESS CENTER, PLLC
Entity Type:Organization
Organization Name:VILLAGE FAMILY CLINIC AND WELLNESS CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:GARRIDO
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, ARNP
Authorized Official - Phone:425-996-3396
Mailing Address - Street 1:317 NW GILMAN BLVD
Mailing Address - Street 2:SUITE 48
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2496
Mailing Address - Country:US
Mailing Address - Phone:425-996-3396
Mailing Address - Fax:
Practice Address - Street 1:317 NW GILMAN BLVD
Practice Address - Street 2:SUITE 48
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2496
Practice Address - Country:US
Practice Address - Phone:425-996-3396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-31
Last Update Date:2008-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004759261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAS59855Medicare UPIN