Healthcare Provider Details

I. General information

NPI: 1316597735
Provider Name (Legal Business Name): MARIANA VERGARA-OCHOA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14090 FRYELANDS BLVD SE STE 347
MONROE WA
98272-2760
US

IV. Provider business mailing address

12332 26TH AVE W
EVERETT WA
98204-4779
US

V. Phone/Fax

Practice location:
  • Phone: 360-805-3122
  • Fax:
Mailing address:
  • Phone: 425-387-6659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCG61003458
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: