Basic Information
| Provider Information | |||||||||
| NPI: | 1922579051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARAHONA | ||||||||
| FirstName: | NOLVIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2612 BOULEVARD PARK CT SE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985014306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604897970 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 627 W FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985843504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607635610 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2018 | ||||||||
| LastUpdateDate: | 12/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | CG60877000 | 05 | WA | MEDICAID |