1184128316 NPI number — MRS. MARISSA RAEANN GONZALEZ DROUYOR MA

Table of content: MRS. MARISSA RAEANN GONZALEZ DROUYOR MA (NPI 1184128316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184128316 NPI number — MRS. MARISSA RAEANN GONZALEZ DROUYOR MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DROUYOR
Provider First Name:
MARISSA
Provider Middle Name:
RAEANN GONZALEZ
Provider Name Prefix Text:
MRS.
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:
GONZALEZ
Provider Other First Name:
MARISSA
Provider Other Middle Name:
RAEANN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
N/A
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184128316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4625 45TH AVE SE APT E12
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LACEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98503-5507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-463-2722
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5401 CORPORATE CENTER LOOP SE STE K11
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98503-5606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-918-8782
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2018

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: 225700000X , with the licence number:  MA60811369 , 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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