Provider Demographics
NPI:1316220577
Name:GODFREY, ALEXANDRA NICOLE (LMP)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:NICOLE
Last Name:GODFREY
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 1:15603 MAIN ST
Mailing Address - Street 2:SUITE B106
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-9003
Mailing Address - Country:US
Mailing Address - Phone:425-948-6495
Mailing Address - Fax:
Practice Address - Street 1:15603 MAIN ST
Practice Address - Street 2:SUITE B106
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-9003
Practice Address - Country:US
Practice Address - Phone:425-948-6495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60185184225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist