Provider Demographics
NPI:1205039153
Name:ABANDO, BOUALOY MANIVANH (LMP)
Entity Type:Individual
Prefix:MRS
First Name:BOUALOY
Middle Name:MANIVANH
Last Name:ABANDO
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 1:1017 S CLOVERDALE ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-4744
Mailing Address - Country:US
Mailing Address - Phone:206-992-6798
Mailing Address - Fax:
Practice Address - Street 1:689 STRANDER BLVD BLDG C
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2922
Practice Address - Country:US
Practice Address - Phone:206-992-6798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist