Provider Demographics
NPI:1255803110
Name:VAHDANI, FARZANEH
Entity type:Individual
Prefix:
First Name:FARZANEH
Middle Name:
Last Name:VAHDANI
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 1:1210 SW 136TH ST
Mailing Address - Street 2:
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1214
Mailing Address - Country:US
Mailing Address - Phone:206-226-7302
Mailing Address - Fax:
Practice Address - Street 1:1210 SW 136TH STREET
Practice Address - Street 2:
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98168
Practice Address - Country:US
Practice Address - Phone:206-226-7302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA171M00000XMedicaid