Basic Information
Provider Information | |||||||||
NPI: | 1598838146 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARPENTER | ||||||||
FirstName: | LESLIE | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MGC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PARKER | ||||||||
OtherFirstName: | LESLIE | ||||||||
OtherMiddleName: | A. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 24366 | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981240366 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2065980502 | ||||||||
FaxNumber: | 2065980516 | ||||||||
Practice Location | |||||||||
Address1: | 1959 NE PACIFIC ST | ||||||||
Address2: |   | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981950001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2065988130 | ||||||||
FaxNumber: | 2065982359 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2006 | ||||||||
LastUpdateDate: | 10/12/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | NA | WA | Y |   | Other Service Providers | Genetic Counselor, MS |   |
ID Information
ID | Type | State | Issuer | Description | U28811 | 01 | WA | REGENCE BLUESHIELD | OTHER |