Provider Demographics
NPI:1023682382
Name:IVANOVA, VERA
Entity type:Individual
Prefix:
First Name:VERA
Middle Name:
Last Name:IVANOVA
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 1:4013 SW 335TH PL
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-2928
Mailing Address - Country:US
Mailing Address - Phone:253-249-9058
Mailing Address - Fax:
Practice Address - Street 1:4013 SW 335TH PL
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98023-2928
Practice Address - Country:US
Practice Address - Phone:253-249-9058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC55003171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter