Provider Demographics
NPI:1851932719
Name:WORMLEY, TELLEY
Entity Type:Individual
Prefix:
First Name:TELLEY
Middle Name:
Last Name:WORMLEY
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:PMB 5054 P.O. BOX 257
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507
Mailing Address - Country:US
Mailing Address - Phone:206-300-5086
Mailing Address - Fax:
Practice Address - Street 1:3625 SE 5TH PL
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-2836
Practice Address - Country:US
Practice Address - Phone:206-300-5086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide