Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 023530 | OR |
NPI | 1013432715 |
---|---|
Provider Name | Stephanie Roseanna Booker |
First Address | Medford, OR 97504-9140 |
Second Address | Medford, OR 97504-9140 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2017 |
Last Update Date | 03/08/2017 |