1609344811 NPI number — SOPHIA KALYNN PEREZ CMA

Table of content: SOPHIA KALYNN PEREZ CMA (NPI 1609344811)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609344811 NPI number — SOPHIA KALYNN PEREZ CMA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PEREZ
Provider First Name:
SOPHIA
Provider Middle Name:
KALYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CMA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PEREZ
Provider Other First Name:
SOPHIA
Provider Other Middle Name:
KALYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CMA
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1609344811
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 HIGHLAND DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUENA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-865-6705
Provider Business Mailing Address Fax Number:
509-865-5011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 HIGHLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZILLAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98953-9716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-865-6705
Provider Business Practice Location Address Fax Number:
509-865-2011
Provider Enumeration Date:
11/06/2018

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: 101YA0400X , with the licence number:  PEREZSK075D7 , 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)

  • Identifier: 91-0755984 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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