Provider Demographics
NPI:1356684195
Name:DESPAIN, TONYA NICHOLE (LMP)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:NICHOLE
Last Name:DESPAIN
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 1:19625 73RD AVE W
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-5803
Mailing Address - Country:US
Mailing Address - Phone:425-244-8883
Mailing Address - Fax:
Practice Address - Street 1:16303 HIGHWAY 99 STE 2B
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98087-1453
Practice Address - Country:US
Practice Address - Phone:425-242-4884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-30
Last Update Date:2013-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60331549174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist