Basic Information
| Provider Information | |||||||||
| NPI: | 1629218912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKETT | ||||||||
| FirstName: | P. | ||||||||
| MiddleName: | FAYE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34581 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092417316 | ||||||||
| FaxNumber: | 5092417628 | ||||||||
| Practice Location | |||||||||
| Address1: | 11511 NE 10TH ST | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980048578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063263671 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2009 | ||||||||
| LastUpdateDate: | 02/25/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 242495 | 01 | WA | LABOR AND INDUSTRIES | OTHER |