Provider Demographics
NPI:1912399072
Name:VAKULICH, TATYANA (LMP)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:VAKULICH
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 S 380TH ST
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003
Mailing Address - Country:US
Mailing Address - Phone:253-661-6366
Mailing Address - Fax:
Practice Address - Street 1:2330 S 380TH ST
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-7714
Practice Address - Country:US
Practice Address - Phone:253-661-6366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60484298225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist