Basic Information
| Provider Information | |||||||||
| NPI: | 1629260534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VICENCIO | ||||||||
| FirstName: | RACHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1608 S J ST | ||||||||
| Address2: | FLOOR 2 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532747503 | ||||||||
| FaxNumber: | 2532747993 | ||||||||
| Practice Location | |||||||||
| Address1: | 1608 S J ST | ||||||||
| Address2: | FLOOR 2 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532747503 | ||||||||
| FaxNumber: | 2532747993 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2007 | ||||||||
| LastUpdateDate: | 11/25/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD60580586 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 8456A | WY | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.