Provider Demographics
NPI:1023388592
Name:THORNLEY, CONNIE MARIE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:THORNLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12800 SE 7TH ST APT H4
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4026
Mailing Address - Country:US
Mailing Address - Phone:360-314-5029
Mailing Address - Fax:
Practice Address - Street 1:17030 SE 1ST ST STE 103
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-8514
Practice Address - Country:US
Practice Address - Phone:360-604-1226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016073225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist