Provider Demographics
NPI:1275921090
Name:TREASURE, MIA NICOLE (LMP)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:NICOLE
Last Name:TREASURE
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 1:2418 NW HAYES RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98674-2218
Mailing Address - Country:US
Mailing Address - Phone:360-907-0139
Mailing Address - Fax:
Practice Address - Street 1:2418 NW HAYES RD
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:WA
Practice Address - Zip Code:98674-2218
Practice Address - Country:US
Practice Address - Phone:360-907-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-31
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60492977174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist