Provider Demographics
NPI:1477987444
Name:CARBONEL, MERCEDES M (NA-R)
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:M
Last Name:CARBONEL
Suffix:
Gender:F
Credentials:NA-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3212 LIBBY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-2985
Mailing Address - Country:US
Mailing Address - Phone:360-357-3918
Mailing Address - Fax:
Practice Address - Street 1:3212 LIBBY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-2985
Practice Address - Country:US
Practice Address - Phone:360-357-3918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA150500171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA453154OtherSOCIAL SERVICE PAYMENT SYSTEM