Provider Demographics
NPI:1831442524
Name:NYSTROM, AMIRA AMAR (LMP)
Entity type:Individual
Prefix:
First Name:AMIRA
Middle Name:AMAR
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 5TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-6201
Mailing Address - Country:US
Mailing Address - Phone:206-854-6268
Mailing Address - Fax:
Practice Address - Street 1:1904 3RD AVE STE 252
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1194
Practice Address - Country:US
Practice Address - Phone:206-682-1424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60255405172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker