Provider Demographics
NPI:1801535588
Name:FOMIN, ANNA VITALEVNA
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:VITALEVNA
Last Name:FOMIN
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 1:5210 N HARVARD RD
Mailing Address - Street 2:
Mailing Address - City:OTIS ORCHARDS
Mailing Address - State:WA
Mailing Address - Zip Code:99027-9282
Mailing Address - Country:US
Mailing Address - Phone:509-475-1551
Mailing Address - Fax:
Practice Address - Street 1:5210 N HARVARD RD
Practice Address - Street 2:
Practice Address - City:OTIS ORCHARDS
Practice Address - State:WA
Practice Address - Zip Code:99027-9282
Practice Address - Country:US
Practice Address - Phone:509-475-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer