Provider Demographics
NPI:1326383944
Name:NICODEMUS, SARAH (LMT)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:NICODEMUS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1536
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-6536
Mailing Address - Country:US
Mailing Address - Phone:360-202-7252
Mailing Address - Fax:
Practice Address - Street 1:902 28TH ST
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-2830
Practice Address - Country:US
Practice Address - Phone:360-202-7252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-07
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009874225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist