Provider Demographics
NPI:1023284122
Name:WALLINGFORD PEDIATRICS PLLC
Entity type:Organization
Organization Name:WALLINGFORD PEDIATRICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:C
Authorized Official - Last Name:NIEBLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-632-0542
Mailing Address - Street 1:PO BOX 31509
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103
Mailing Address - Country:US
Mailing Address - Phone:206-632-0542
Mailing Address - Fax:
Practice Address - Street 1:4005 WALLINGFORD AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-8218
Practice Address - Country:US
Practice Address - Phone:206-632-0542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00012418173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0057688OtherL & I
WA1097559OtherDSHS