Basic Information
| Provider Information | |||||||||
| NPI: | 1114047651 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4220 132ND ST SE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MILL CREEK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980128999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253579380 | ||||||||
| FaxNumber: | 4253579382 | ||||||||
| Practice Location | |||||||||
| Address1: | 5029 EVERGREEN WAY | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252521642 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 12/03/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA00022970 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 602646989 | 01 | WA | UNIFIED BUSINESS ID | OTHER | 0229624 | 01 | WA | DEPT L&I | OTHER | 8946939 | 01 | WA | L&I CRIME VICTIMS | OTHER | MA00022970 | 01 | WA | WA STATE MASSAGE LICENSE | OTHER | 0016EV | 01 | WA | REGENCE | OTHER |