Provider Demographics
NPI:1114456571
Name:MOORE, VIRGINIA WYNN (LMT)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:WYNN
Last Name:MOORE
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 1:535 PONTIUS AVE N APT 402
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-5589
Mailing Address - Country:US
Mailing Address - Phone:713-542-7417
Mailing Address - Fax:
Practice Address - Street 1:535 PONTIUS AVE N
Practice Address - Street 2:APT 402
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98109
Practice Address - Country:US
Practice Address - Phone:713-542-7417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60668300225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist