1114521192 NPI number — MRS. REGAN RAE KAMMA BOLING LSWAIC, LSW

Table of content: CHARLES E DOMINGUEZ O.D. (NPI 1063437507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114521192 NPI number — MRS. REGAN RAE KAMMA BOLING LSWAIC, LSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLING
Provider First Name:
REGAN
Provider Middle Name:
RAE KAMMA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LSWAIC, LSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FERRELL
Provider Other First Name:
REGAN
Provider Other Middle Name:
RAE KAMMA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114521192
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11030 NE 58TH WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KIRKLAND
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98033-7506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-450-2143
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16521 13TH AVE W STE 112
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNNWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98037-8513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-450-2143
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2020

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: 104100000X , with the licence number:  SC61108110 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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