Basic Information
| Provider Information | |||||||||
| NPI: | 1447890512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURRELL | ||||||||
| FirstName: | LETICIA | ||||||||
| MiddleName: | JO | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | GONZALEZ | ||||||||
| OtherFirstName: | LETICIA | ||||||||
| OtherMiddleName: | JO | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 107 S DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992021510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098384651 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 124 E SHORT AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992021555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098384651 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2020 | ||||||||
| LastUpdateDate: | 02/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 175T00000X | CG61031957 | WA | Y |
No ID Information.