Healthcare Provider Details

I. General information

NPI: 1598685653
Provider Name (Legal Business Name): MARISELA J MONTELONGO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 S 15TH AVE
YAKIMA WA
98902-3823
US

IV. Provider business mailing address

419 S 15TH AVE
YAKIMA WA
98902-3823
US

V. Phone/Fax

Practice location:
  • Phone: 509-517-8213
  • Fax:
Mailing address:
  • Phone: 509-527-8213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: