Provider Demographics
NPI:1235779919
Name:CHURCH, LAURA ELIZABETH
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:ELIZABETH
Last Name:CHURCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 19TH AVE E APT 7
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-5344
Mailing Address - Country:US
Mailing Address - Phone:910-274-4585
Mailing Address - Fax:
Practice Address - Street 1:10021 HOLMAN RD NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98177-4920
Practice Address - Country:US
Practice Address - Phone:206-632-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60964116225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist