Provider Demographics
NPI:1154851780
Name:MCILWAIN, AMARIS (LMP)
Entity Type:Individual
Prefix:
First Name:AMARIS
Middle Name:
Last Name:MCILWAIN
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 1:818 SE 119TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-5243
Mailing Address - Country:US
Mailing Address - Phone:360-721-2920
Mailing Address - Fax:
Practice Address - Street 1:3200 SE 164TH AVE STE 212
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-1108
Practice Address - Country:US
Practice Address - Phone:360-406-4884
Practice Address - Fax:360-721-2920
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist