Provider Demographics
NPI:1316139470
Name:SEBOULISA, NANDI (LMP)
Entity type:Individual
Prefix:
First Name:NANDI
Middle Name:
Last Name:SEBOULISA
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 N 12TH ST
Mailing Address - Street 2:#3
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98403-1801
Mailing Address - Country:US
Mailing Address - Phone:253-468-4210
Mailing Address - Fax:253-627-3433
Practice Address - Street 1:1101 N 12TH ST
Practice Address - Street 2:#3
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98403-1801
Practice Address - Country:US
Practice Address - Phone:253-468-4210
Practice Address - Fax:253-627-3433
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015108174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist