Provider Demographics
NPI:1114066990
Name:PROBST, RENEE CHARISE (LMP)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:CHARISE
Last Name:PROBST
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:PO BOX 731704
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-0017
Mailing Address - Country:US
Mailing Address - Phone:253-861-9983
Mailing Address - Fax:253-460-1920
Practice Address - Street 1:4103 BRIDGEPORT WAY W STE C
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4332
Practice Address - Country:US
Practice Address - Phone:253-460-1824
Practice Address - Fax:253-460-1920
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA17907174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist