Provider Demographics
NPI:1992986640
Name:SEVILLE, VIVIAN (CNA, LMT)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:SEVILLE
Suffix:
Gender:F
Credentials:CNA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2453
Mailing Address - Street 2:
Mailing Address - City:PINE
Mailing Address - State:AZ
Mailing Address - Zip Code:85544-2453
Mailing Address - Country:US
Mailing Address - Phone:928-978-2618
Mailing Address - Fax:928-476-3186
Practice Address - Street 1:6152 W. HARDSCRABBLE ROAD
Practice Address - Street 2:
Practice Address - City:PINE
Practice Address - State:AZ
Practice Address - Zip Code:85544
Practice Address - Country:US
Practice Address - Phone:928-978-2618
Practice Address - Fax:928-476-3186
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-02072P174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist