Provider Demographics
NPI:1114749744
Name:FOSSEN-TAMAYO, KAILIYAH LUNING
Entity type:Individual
Prefix:
First Name:KAILIYAH
Middle Name:LUNING
Last Name:FOSSEN-TAMAYO
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 1:108 TULSA AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5197 NW LOWER RIVER RD BLDG 1
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-1013
Practice Address - Country:US
Practice Address - Phone:360-205-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator