Provider Demographics
NPI:1952966996
Name:MOLCHANOVA, TATYANA IVANOVNA
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:IVANOVNA
Last Name:MOLCHANOVA
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 1:5306 NE 54TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-2197
Mailing Address - Country:US
Mailing Address - Phone:503-919-5812
Mailing Address - Fax:
Practice Address - Street 1:203 SE PARK PLAZA DR STE 140
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5887
Practice Address - Country:US
Practice Address - Phone:503-813-2619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00175960163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA123123OtherN/A
WA123123Medicaid