1225738859 NPI number — HEATHER ANN IVY SUDP III

Table of content: HEATHER ANN IVY SUDP III (NPI 1225738859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225738859 NPI number — HEATHER ANN IVY SUDP III

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IVY
Provider First Name:
HEATHER
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SUDP III
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SAMPLE
Provider Other First Name:
HEATHER
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
SUDP-T
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1225738859
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9650 15TH AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98106-2576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-965-1055
Provider Business Mailing Address Fax Number:
206-965-1032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1415 CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98409-8210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-280-9860
Provider Business Practice Location Address Fax Number:
253-280-9870
Provider Enumeration Date:
03/02/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  CP61678744 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 390200000X , with the licence number: CO61296221 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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