1356881536 NPI number — DIANE FABIAN LAC

Table of content: DIANE FABIAN LAC (NPI 1356881536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356881536 NPI number — DIANE FABIAN LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FABIAN
Provider First Name:
DIANE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAC
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:
1356881536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
221 W RAILROAD AVE, SUITE L
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHELTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98584
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-339-4050
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
502 S STILL RD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEQUIM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98382-3578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-339-4050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2017

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: 171100000X , with the licence number:  AC 60694692 , 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)





Copyright © 2007-2025 www.npivalidator.com