Basic Information
| Provider Information | |||||||||
| NPI: | 1235415670 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAM | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1401 MERRILL CREEK PKWY | ||||||||
| Address2: | #6028 | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982037133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549310472 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15 SW EVERETT MALL WAY | ||||||||
| Address2: | STE G | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982042715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253555222 | ||||||||
| FaxNumber: | 4253555231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2011 | ||||||||
| LastUpdateDate: | 04/18/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | CHIR008846 | GA | N | Chiropractic Providers | Chiropractor | 111N00000X | CHIR008845 | GA | N | Chiropractic Providers | Chiropractor | 111N00000X | CH 10709 | FL | N | Chiropractic Providers | Chiropractor | 111N00000X | CH60742209 | WA | Y | Chiropractic Providers | Chiropractor |
No ID Information.