Provider Demographics
NPI:1376060772
Name:PINKHAM, RENE AMELIA (LMP MA 60485559)
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:AMELIA
Last Name:PINKHAM
Suffix:
Gender:F
Credentials:LMP MA 60485559
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13739 RAWLINS RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-7132
Mailing Address - Country:US
Mailing Address - Phone:425-210-1621
Mailing Address - Fax:
Practice Address - Street 1:125 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257
Practice Address - Country:US
Practice Address - Phone:425-210-1621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6048559225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist