Provider Demographics
NPI:1275951154
Name:SAMUEL, MANITA G (EAMP LAC)
Entity Type:Individual
Prefix:MRS
First Name:MANITA
Middle Name:G
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:EAMP LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17022 NE 100TH PL
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3177
Mailing Address - Country:US
Mailing Address - Phone:425-242-0853
Mailing Address - Fax:
Practice Address - Street 1:17022 NE 100TH PL
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3177
Practice Address - Country:US
Practice Address - Phone:425-242-0853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC 60447864171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist