Provider Demographics
NPI:1649782681
Name:FUNCTIONAL MEDICINE NORTHWEST
Entity type:Organization
Organization Name:FUNCTIONAL MEDICINE NORTHWEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ILLER
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:206-268-0397
Mailing Address - Street 1:8010 15TH AVE NW
Mailing Address - Street 2:SUITE D
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98117
Mailing Address - Country:US
Mailing Address - Phone:206-268-0397
Mailing Address - Fax:206-518-9225
Practice Address - Street 1:8010 15TH AVE NW
Practice Address - Street 2:SUITE D
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98117
Practice Address - Country:US
Practice Address - Phone:206-268-0397
Practice Address - Fax:206-518-9225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60115399261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care