Provider Demographics
NPI:1295193092
Name:POLOZKOVA, ELENA
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:POLOZKOVA
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 1:1302 FARALLONE AVE
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6700
Mailing Address - Country:US
Mailing Address - Phone:304-932-4872
Mailing Address - Fax:
Practice Address - Street 1:1302 FARALLONE AVE
Practice Address - Street 2:
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6700
Practice Address - Country:US
Practice Address - Phone:304-932-4872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60583021225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist