Provider Demographics
NPI:1447893748
Name:SULAKOV, MARIYA (ND)
Entity type:Individual
Prefix:
First Name:MARIYA
Middle Name:
Last Name:SULAKOV
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25500 SE STARK ST
Mailing Address - Street 2:ST 202
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3331
Mailing Address - Country:US
Mailing Address - Phone:503-489-5917
Mailing Address - Fax:503-489-9210
Practice Address - Street 1:25500 SE STARK ST
Practice Address - Street 2:ST 202
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2441
Practice Address - Country:US
Practice Address - Phone:503-489-5917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-20
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4264175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath