Healthcare Provider Details

I. General information

NPI: 1619343191
Provider Name (Legal Business Name): LAUREN CHRISTINE DIFOLCO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10920 199TH AVE. CT. E. BONNEY LAKE HS,
BONNEY LAKE WA
98391
US

IV. Provider business mailing address

1221 MOTTMAN RD SW APT D203
TUMWATER WA
98512-6391
US

V. Phone/Fax

Practice location:
  • Phone: 253-891-5700
  • Fax:
Mailing address:
  • Phone: 720-425-4641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number516288H
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: