Basic Information
| Provider Information | |||||||||
| NPI: | 1306800354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENNELLA | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | F. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E. KINCAID STREET | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604282500 | ||||||||
| FaxNumber: | 3604286485 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 E. KINCAID STREET | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604286434 | ||||||||
| FaxNumber: | 3608484233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 11/29/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD00022793 | WA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | MD00022793 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 263545 | 01 | WA | LABOR & INDUSTRIES | OTHER | 1007152 | 05 | WA | MEDICAID |