Provider Demographics
NPI:1720426372
Name:VILLAGE PEDIATRICS, PLLC
Entity type:Organization
Organization Name:VILLAGE PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:STACI
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:814-387-8224
Mailing Address - Street 1:1975 25TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-7737
Mailing Address - Country:US
Mailing Address - Phone:814-387-8224
Mailing Address - Fax:
Practice Address - Street 1:317 NW GILMAN BLVD STE 48
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2485
Practice Address - Country:US
Practice Address - Phone:425-996-3396
Practice Address - Fax:425-996-0231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60081924261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care