Provider Demographics
NPI:1235464736
Name:PROCTOR, GLORIA ANN (LMP)
Entity Type:Individual
Prefix:MS
First Name:GLORIA
Middle Name:ANN
Last Name:PROCTOR
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:P O BOX 98244
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:WA
Mailing Address - Zip Code:98198-0244
Mailing Address - Country:US
Mailing Address - Phone:206-878-6940
Mailing Address - Fax:206-870-1940
Practice Address - Street 1:22201 MARINEVIEW DRIVE S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-0244
Practice Address - Country:US
Practice Address - Phone:206-878-6940
Practice Address - Fax:206-870-1940
Is Sole Proprietor?:No
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00005858225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA103543OtherLABOR & INDUSTRY