Basic Information
| Provider Information | |||||||||
| NPI: | 1790161578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCNUTT | ||||||||
| FirstName: | EMMA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | LMP | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | FORSLUND | ||||||||
| OtherFirstName: | EMMA | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
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| OtherCredential: | LMP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4040 ORCHARD ST W | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | FIRCREST | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984666606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535641560 | ||||||||
| FaxNumber: | 2535644449 | ||||||||
| Practice Location | |||||||||
| Address1: | 7308 BRIDGEPORT WAY W | ||||||||
| Address2: | STE. 103 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984998000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535828142 | ||||||||
| FaxNumber: | 2535828160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2015 | ||||||||
| LastUpdateDate: | 10/06/2017 | ||||||||
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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 | MA60581423 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.