Provider Demographics
NPI:1184267742
Name:FANNIN, PEIWEN WANG (EAMP, LAC)
Entity type:Individual
Prefix:
First Name:PEIWEN
Middle Name:WANG
Last Name:FANNIN
Suffix:
Gender:F
Credentials:EAMP, LAC
Other - Prefix:
Other - First Name:PEI WEN
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EAMP, LAC
Mailing Address - Street 1:18120 102ND AVE NE APT 320
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-3490
Mailing Address - Country:US
Mailing Address - Phone:206-335-1213
Mailing Address - Fax:
Practice Address - Street 1:17311 135TH AVE NE STE A250
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-7084
Practice Address - Country:US
Practice Address - Phone:425-408-0040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC61005822171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty