Provider Demographics
NPI:1336485556
Name:VIFQUAIN, KATELYNN (LAC)
Entity Type:Individual
Prefix:
First Name:KATELYNN
Middle Name:
Last Name:VIFQUAIN
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 1:813 RINCON WAY
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2923
Mailing Address - Country:US
Mailing Address - Phone:415-254-0831
Mailing Address - Fax:
Practice Address - Street 1:292 RED HILL AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2452
Practice Address - Country:US
Practice Address - Phone:415-254-0831
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-15
Last Update Date:2012-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15118171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist