Provider Demographics
NPI:1720851173
Name:FONSECA, ARIEL LEILANI (LMT)
Entity Type:Individual
Prefix:
First Name:ARIEL
Middle Name:LEILANI
Last Name:FONSECA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21651 E COUNTRY VISTA DR STE F
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-7709
Mailing Address - Country:US
Mailing Address - Phone:509-319-2310
Mailing Address - Fax:509-319-2341
Practice Address - Street 1:21651 E COUNTRY VISTA DR STE F
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-7709
Practice Address - Country:US
Practice Address - Phone:509-319-2310
Practice Address - Fax:509-319-2341
Is Sole Proprietor?:No
Enumeration Date:2023-11-06
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61173178225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist