Provider Demographics
NPI:1063022952
Name:BRICENO, KARLA IVONNE
Entity Type:Individual
Prefix:
First Name:KARLA
Middle Name:IVONNE
Last Name:BRICENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20525 12TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:SPANAWAY
Mailing Address - State:WA
Mailing Address - Zip Code:98387-8539
Mailing Address - Country:US
Mailing Address - Phone:253-222-7818
Mailing Address - Fax:
Practice Address - Street 1:20525 12TH AVENUE CT E
Practice Address - Street 2:
Practice Address - City:SPANAWAY
Practice Address - State:WA
Practice Address - Zip Code:98387-8539
Practice Address - Country:US
Practice Address - Phone:253-222-7818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC54412171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0409889OtherLABOR AND INDUSTRIES SERVICE PROVIDER NUMBER