Basic Information
| Provider Information | |||||||||
| NPI: | 1730136334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALMBORG OKELLEY | ||||||||
| FirstName: | TYRA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT | ||||||||
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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: | 982032826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252521642 | ||||||||
| FaxNumber: | 4252581824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| 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 | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5028MA | 01 | WA | REGENCE BLUE SHIELD | OTHER | 8385379 | 05 | WA | MEDICAID | 0264717 | 01 | WA | DEPT OF L&I | OTHER | 8875MA | 01 | WA | REGENCE BLUE SHIELD | OTHER | 2358MA | 01 | WA | REGENCE BLUE SHIELD | OTHER | 4524MA | 01 | WA | REGENCE BLUE SHIELD | OTHER | 5342MA | 01 | WA | REGENCE BLUE SHIELD | OTHER | 911745305-98203-C007 | 01 | WA | TRICARE | OTHER | 0201977 | 01 | WA | DEPT. OF LABOR & INDUSTRY | OTHER | 0562MA | 01 | WA | REGENCE | OTHER | 8542MA | 01 | WA | REGENCE BLUE SHIELD | OTHER | 8935654 | 01 | WA | L&I CRIME VICTIMS | OTHER | 911745305-98275-A004 | 01 | WA | TRICARE | OTHER | 5066111 | 01 | WA | AETNA | OTHER |