Provider Demographics
NPI:1225493174
Name:BALLANTYNE, LISA (ND, LMP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BALLANTYNE
Suffix:
Gender:F
Credentials:ND, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 HARPER HILL RD SE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-8931
Mailing Address - Country:US
Mailing Address - Phone:801-712-2228
Mailing Address - Fax:
Practice Address - Street 1:205 BETHEL AVE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-5215
Practice Address - Country:US
Practice Address - Phone:801-712-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-19
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60512799225700000X
WANT60799749175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist