Provider Demographics
NPI:1649479437
Name:FONCECA, MOLLIE ANN
Entity type:Individual
Prefix:MRS
First Name:MOLLIE
Middle Name:ANN
Last Name:FONCECA
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 1:815 103RD DR SE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-9458
Mailing Address - Country:US
Mailing Address - Phone:425-334-9287
Mailing Address - Fax:
Practice Address - Street 1:815 103RD DR SE
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-9458
Practice Address - Country:US
Practice Address - Phone:425-334-9287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024274225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist