Provider Demographics
NPI:1407979719
Name:WILSON, MICHELLE LYNN (LMP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:HANNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:5750 RUDDELL RD SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5100
Mailing Address - Country:US
Mailing Address - Phone:360-412-8286
Mailing Address - Fax:360-412-7403
Practice Address - Street 1:5750 RUDDELL RD SE
Practice Address - Street 2:SUITE B
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5100
Practice Address - Country:US
Practice Address - Phone:360-412-8286
Practice Address - Fax:360-412-7403
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020296225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist