Basic Information
| Provider Information | |||||||||
| NPI: | 1619582871 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENAO | ||||||||
| FirstName: | MARLON | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 901 RAINIER AVE S | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981442839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2068180817 | ||||||||
| FaxNumber: | 2064703857 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 RAINIER AVE S | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981442839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2068180817 | ||||||||
| FaxNumber: | 2064703857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2020 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | CG61097214 | WA | N | Other Service Providers | Community Health Worker | 175T00000X | CG61097214 | WA | Y |
No ID Information.