MEDICARE: SOPHIA LARAINE NIETO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183700000X	Pharmacy Technician	VA00052295	WA

General Provider Information

NPI Number	:	1649250432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHIA LARAINE NIETO

Provider Business Mailing Address
First Line	:	3022 SW 109TH ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98146-1777
Country	:	US
Telephone Number	:	206-988-0596
Fax Number	:

Provider Business Practice Location Address
First Line	:	3022 SW 109TH ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98146-1777
Country	:	US
Telephone Number	:	206-988-0596
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2006
Last Update Date	:	07/08/2007

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