Provider Demographics
NPI:1396033742
Name:CARLSON, CHEYANNA MAE (LMP)
Entity Type:Individual
Prefix:
First Name:CHEYANNA
Middle Name:MAE
Last Name:CARLSON
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 1:15026 40TH AVE W
Mailing Address - Street 2:4-302
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087-8952
Mailing Address - Country:US
Mailing Address - Phone:619-818-7659
Mailing Address - Fax:
Practice Address - Street 1:14700 NE 8TH ST
Practice Address - Street 2:#115
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-4115
Practice Address - Country:US
Practice Address - Phone:425-644-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60230431174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist