Provider Demographics
NPI:1093329088
Name:IBARRA, TABITA G
Entity Type:Individual
Prefix:
First Name:TABITA
Middle Name:G
Last Name:IBARRA
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 1:1916 N 30TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-8914
Mailing Address - Country:US
Mailing Address - Phone:360-550-0669
Mailing Address - Fax:
Practice Address - Street 1:1916 N 30TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-8914
Practice Address - Country:US
Practice Address - Phone:360-550-0669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC12986171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter