1215410550 NPI number — IVELISSE VALLELLANES SANTIAGO MA

Table of content: IVELISSE VALLELLANES SANTIAGO MA (NPI 1215410550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215410550 NPI number — IVELISSE VALLELLANES SANTIAGO MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VALLELLANES SANTIAGO
Provider First Name:
IVELISSE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215410550
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1650 HONEYSUCKLE LN SW APT 22-304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUMWATER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98512-6099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
939-777-6978
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
627 W FRANKLIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98584-3504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-763-5610
Provider Business Practice Location Address Fax Number:
360-462-0449
Provider Enumeration Date:
09/12/2018

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CG60880238 . This is a "AGENCY AFFILIATED COUNSELO" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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