Provider Demographics
NPI:1629260534
Name:VICENCIO, RACHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:RACHELLE
Middle Name:
Last Name:VICENCIO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 S J ST
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4930
Mailing Address - Country:US
Mailing Address - Phone:253-274-7503
Mailing Address - Fax:253-274-7993
Practice Address - Street 1:1608 S J ST
Practice Address - Street 2:FLOOR 2
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4930
Practice Address - Country:US
Practice Address - Phone:253-274-7503
Practice Address - Fax:253-274-7993
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60580586208000000X
WY8456A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics