Healthcare Provider Details

I. General information

NPI: 1710895651
Provider Name (Legal Business Name): FREDERICK TAUTALA FATIALOFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3622 116TH AVENUE CT E
EDGEWOOD WA
98372-2403
US

IV. Provider business mailing address

3622 116TH AVENUE CT E
EDGEWOOD WA
98372-2403
US

V. Phone/Fax

Practice location:
  • Phone: 253-316-9267
  • Fax:
Mailing address:
  • Phone: 253-316-9267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: