Provider Demographics
NPI:1417022849
Name:BENNETT, MELANIE MOORE (LMP)
Entity Type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:MOORE
Last Name:BENNETT
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 1:2728 31ST CT SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-3916
Mailing Address - Country:US
Mailing Address - Phone:360-352-7249
Mailing Address - Fax:
Practice Address - Street 1:1610 BISHOP RD SW
Practice Address - Street 2:STE 103
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7303
Practice Address - Country:US
Practice Address - Phone:360-459-9000
Practice Address - Fax:360-459-9183
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMAOOOO6291225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA140315OtherL&I
WA0642BEOtherREGENCE