Provider Demographics
NPI:1588134597
Name:KIRILLOV, YELENA A (MAO)
Entity type:Individual
Prefix:
First Name:YELENA
Middle Name:A
Last Name:KIRILLOV
Suffix:
Gender:F
Credentials:MAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4031 ADDY ST
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-2726
Mailing Address - Country:US
Mailing Address - Phone:360-904-0918
Mailing Address - Fax:
Practice Address - Street 1:4031 ADDY ST
Practice Address - Street 2:
Practice Address - City:WASHOUGAL
Practice Address - State:WA
Practice Address - Zip Code:98671-2726
Practice Address - Country:US
Practice Address - Phone:360-904-0918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60912426171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty