Provider Demographics
NPI:1114143476
Name:VANDERWAY, MICHELLE ELAINE (LMP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELAINE
Last Name:VANDERWAY
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 842
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-0842
Mailing Address - Country:US
Mailing Address - Phone:206-679-7372
Mailing Address - Fax:425-397-6179
Practice Address - Street 1:1052 STATE AVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270
Practice Address - Country:US
Practice Address - Phone:206-679-7372
Practice Address - Fax:425-397-6179
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022203225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist