Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | MA60255471 | WA |
NPI | 1013398163 |
---|---|
Provider Name | Miranda Blythe Lucker |
First Address | Sumner, WA 98390-2715 |
Second Address | Sumner, WA 98390-2715 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2015 |
Last Update Date | 30/03/2017 |