Provider Demographics
NPI:1033692397
Name:WILSON, MICHELLE LYN (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12402 ADMIRALTY WAY APT J205
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-8584
Mailing Address - Country:US
Mailing Address - Phone:425-583-2917
Mailing Address - Fax:
Practice Address - Street 1:2902 164TH ST SW STE D1
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98087-3201
Practice Address - Country:US
Practice Address - Phone:425-279-5906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60811330225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist