Provider Demographics
NPI:1144397183
Name:YAN, AUDREY M (LMP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:M
Last Name:YAN
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 1:9620 S 203RD ST
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-1463
Mailing Address - Country:US
Mailing Address - Phone:253-854-1823
Mailing Address - Fax:253-854-1823
Practice Address - Street 1:24604 104TH AVE SE # 203
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-4965
Practice Address - Country:US
Practice Address - Phone:253-859-2373
Practice Address - Fax:253-856-8754
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00005757225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA31651OtherL&I PROVIDE NUMBER
WA31651OtherL&I PROVIDE NUMBER