Provider Demographics
NPI:1356932214
Name:DERGHAM, KATIA ROSE (CGC)
Entity type:Individual
Prefix:
First Name:KATIA
Middle Name:ROSE
Last Name:DERGHAM
Suffix:
Gender:F
Credentials:CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:4033 TALBOT RD S STE 470
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5700
Practice Address - Country:US
Practice Address - Phone:425-690-3677
Practice Address - Fax:425-690-9677
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAGT61166257170300000X
170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS