Provider Demographics
NPI:1275118481
Name:SIMONELLI, DEEDRA ANN (MA60228974)
Entity Type:Individual
Prefix:
First Name:DEEDRA
Middle Name:ANN
Last Name:SIMONELLI
Suffix:
Gender:F
Credentials:MA60228974
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18705 126TH AVE NE APT 2703
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-9349
Mailing Address - Country:US
Mailing Address - Phone:206-533-3348
Mailing Address - Fax:
Practice Address - Street 1:16825 48TH AVE W STE 243
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98037-6406
Practice Address - Country:US
Practice Address - Phone:206-533-3348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60228974225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty