Provider Demographics
NPI:1194194381
Name:DEFAZIO, MOLLY ANN (LAC)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANN
Last Name:DEFAZIO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 HARVEY RD NE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-4225
Mailing Address - Country:US
Mailing Address - Phone:425-736-1995
Mailing Address - Fax:
Practice Address - Street 1:819 HARVEY RD NE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4225
Practice Address - Country:US
Practice Address - Phone:425-780-7502
Practice Address - Fax:888-975-7980
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00000674171100000X
WA674171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist