Provider Demographics
NPI:1376672824
Name:WANE, NICOLE SUSANNE (LAC)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:SUSANNE
Last Name:WANE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2814 NE 55TH ST
Mailing Address - Street 2:APT 5
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-5513
Mailing Address - Country:US
Mailing Address - Phone:206-979-6937
Mailing Address - Fax:206-524-0709
Practice Address - Street 1:2817 NE 55TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-5529
Practice Address - Country:US
Practice Address - Phone:206-979-6937
Practice Address - Fax:206-524-0709
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC00002832171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist