Provider Demographics
NPI:1366868077
Name:DAVID, VASILICA
Entity Type:Individual
Prefix:MRS
First Name:VASILICA
Middle Name:
Last Name:DAVID
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 1:3509 S 272ND ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-7062
Mailing Address - Country:US
Mailing Address - Phone:253-859-3220
Mailing Address - Fax:253-859-3220
Practice Address - Street 1:3509 S 272ND ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-7062
Practice Address - Country:US
Practice Address - Phone:253-859-3220
Practice Address - Fax:253-859-3220
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA750042311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA768846Medicaid