Provider Demographics
NPI:1275220337
Name:MUNOZ RIVAS, EDNA FABIOLA
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:FABIOLA
Last Name:MUNOZ RIVAS
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 1:827 MILLS PL NE
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98045-9440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17090 AVONDALE WAY NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-4409
Practice Address - Country:US
Practice Address - Phone:425-780-7208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61170676225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty