Provider Demographics
NPI:1164823621
Name:MITCHELL, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14101 NE 37TH CIR
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-8761
Mailing Address - Country:US
Mailing Address - Phone:360-980-2960
Mailing Address - Fax:
Practice Address - Street 1:14313 NE 20TH AVE
Practice Address - Street 2:SUITE A112
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1487
Practice Address - Country:US
Practice Address - Phone:360-980-2960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60493118225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist