Provider Demographics
NPI:1114047651
Name:EVANS, MELANIE SUE (LMP)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:SUE
Last Name:EVANS
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 1:4220 132ND ST SE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8999
Mailing Address - Country:US
Mailing Address - Phone:425-357-9380
Mailing Address - Fax:425-357-9382
Practice Address - Street 1:5029 EVERGREEN WAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203
Practice Address - Country:US
Practice Address - Phone:425-252-1642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022970225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA602646989OtherUNIFIED BUSINESS ID
WA0229624OtherDEPT L&I
WA8946939OtherL&I CRIME VICTIMS
WAMA00022970OtherWA STATE MASSAGE LICENSE
WA0016EVOtherREGENCE