Provider Demographics
NPI:1427672310
Name:CISTULLI, ANDREA LAUREN (DO)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:LAUREN
Last Name:CISTULLI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 FAUNTLEROY WAY SW STE 100
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-3471
Mailing Address - Country:US
Mailing Address - Phone:206-933-1041
Mailing Address - Fax:206-933-1047
Practice Address - Street 1:4550 FAUNTLEROY WAY SW STE 100
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-3471
Practice Address - Country:US
Practice Address - Phone:206-933-1041
Practice Address - Fax:206-933-1047
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61303898207Q00000X
WAOL61068580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2160381Medicaid