Provider Demographics
NPI:1033512934
Name:LINCECUM, ROSANNA (LMP)
Entity Type:Individual
Prefix:
First Name:ROSANNA
Middle Name:
Last Name:LINCECUM
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 E HOMESTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4817
Mailing Address - Country:US
Mailing Address - Phone:907-232-6305
Mailing Address - Fax:
Practice Address - Street 1:2510 N PINES RD STE 207
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-7636
Practice Address - Country:US
Practice Address - Phone:907-232-6305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-998225700000X
WAMA60269955225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist