Provider Demographics
NPI:1235672882
Name:FORKNER, TERRA MARIE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:TERRA
Middle Name:MARIE
Last Name:FORKNER
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 1:17360 RED HAWK CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-7797
Mailing Address - Country:US
Mailing Address - Phone:360-610-1089
Mailing Address - Fax:360-989-1197
Practice Address - Street 1:1202 S. 2ND STREET
Practice Address - Street 2:SUITE E
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:360-610-1089
Practice Address - Fax:360-989-1197
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-30
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60644252225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist