Provider Demographics
NPI:1164820668
Name:KHOMLYAK, MARIYA (NAR)
Entity Type:Individual
Prefix:
First Name:MARIYA
Middle Name:
Last Name:KHOMLYAK
Suffix:
Gender:F
Credentials:NAR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 SHATTUCK PL S
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-4289
Mailing Address - Country:US
Mailing Address - Phone:425-277-0452
Mailing Address - Fax:425-271-1107
Practice Address - Street 1:2111 SHATTUCK PL S
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-4289
Practice Address - Country:US
Practice Address - Phone:425-277-0452
Practice Address - Fax:425-271-1107
Is Sole Proprietor?:No
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA750970171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA156016OtherSOCIAL SERVICE PAYMENT SYSTEM NUMBER