Provider Demographics
NPI:1992882187
Name:CARTMELL, JOHN WALTER (CN)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WALTER
Last Name:CARTMELL
Suffix:
Gender:M
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9805 AVONDALE RD NE
Mailing Address - Street 2:APT. H126
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-2946
Mailing Address - Country:US
Mailing Address - Phone:425-883-7444
Mailing Address - Fax:
Practice Address - Street 1:8226 196TH AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98053-7536
Practice Address - Country:US
Practice Address - Phone:425-883-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU00001711133N00000X
WAMA00002070225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP100009554110001Medicaid
WAP100009554110001Medicaid