Provider Demographics
NPI:1376250530
Name:SILAN, MANUELA JARDINE SAMSON (MA60892346)
Entity Type:Individual
Prefix:
First Name:MANUELA JARDINE
Middle Name:SAMSON
Last Name:SILAN
Suffix:
Gender:F
Credentials:MA60892346
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 10TH ST STE 219
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-7053
Mailing Address - Country:US
Mailing Address - Phone:408-722-0049
Mailing Address - Fax:
Practice Address - Street 1:1140 10TH ST STE 219
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-7053
Practice Address - Country:US
Practice Address - Phone:408-722-0049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60892346225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA603566427OtherUNIFIED BUSINESS ID