Basic Information
Provider Information | |||||||||
NPI: | 1801374814 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DOMBEK | ||||||||
FirstName: | DANIELLE | ||||||||
MiddleName: | BETHANY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 9301 AVONDALE RD NE APT J2053 | ||||||||
Address2: |   | ||||||||
City: | REDMOND | ||||||||
State: | WA | ||||||||
PostalCode: | 980523354 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8144043865 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3925 159TH AVE NE | ||||||||
Address2: |   | ||||||||
City: | REDMOND | ||||||||
State: | WA | ||||||||
PostalCode: | 980526309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4252160550 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2018 | ||||||||
LastUpdateDate: | 08/01/2018 | ||||||||
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 | 174H00000X |   |   | Y |   | Other Service Providers | Health Educator |   |
No ID Information.