Provider Demographics
NPI:1225551310
Name:NICOLOSI, LAURA (LMP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:NICOLOSI
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:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98045-0087
Mailing Address - Country:US
Mailing Address - Phone:425-888-5060
Mailing Address - Fax:866-433-9842
Practice Address - Street 1:410 E NORTH BEND WAY
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98045
Practice Address - Country:US
Practice Address - Phone:425-888-5060
Practice Address - Fax:866-433-9842
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60755014225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist