1174272090 NPI number — STEPHANIE MAE TUMBA MC61119663

Table of content: MRS. DESPINA KOTSOYIANNIS (NPI 1649887555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174272090 NPI number — STEPHANIE MAE TUMBA MC61119663

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUMBA
Provider First Name:
STEPHANIE
Provider Middle Name:
MAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MC61119663
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COOKE
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
MAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174272090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3206 W GARLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99205-2231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-455-5508
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3206 W GARLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99205-2231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-455-5508
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/18/2022

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 , with the licence number:  MC61119663 , 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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