Provider Demographics
NPI:1255661849
Name:WYZGA, MICHELE ADELAIDE (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:ADELAIDE
Last Name:WYZGA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6822 NE BERGMAN RD
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE IS
Mailing Address - State:WA
Mailing Address - Zip Code:98110-1285
Mailing Address - Country:US
Mailing Address - Phone:206-290-8900
Mailing Address - Fax:
Practice Address - Street 1:9445 NE BUSINESS PARK LN
Practice Address - Street 2:STE 203
Practice Address - City:BAINBRIDGE IS
Practice Address - State:WA
Practice Address - Zip Code:98110-4634
Practice Address - Country:US
Practice Address - Phone:206-290-8900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024674225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist