Provider Demographics
NPI:1225434160
Name:DEROUIN, MICHELE (LMP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:DEROUIN
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 1:502 50TH ST SE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98092-9499
Mailing Address - Country:US
Mailing Address - Phone:808-398-9105
Mailing Address - Fax:
Practice Address - Street 1:502 50TH ST SE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98092-9499
Practice Address - Country:US
Practice Address - Phone:808-398-9105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015655174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist