Provider Demographics
NPI:1417190208
Name:DE SARIO, NIKI (LMP)
Entity Type:Individual
Prefix:
First Name:NIKI
Middle Name:
Last Name:DE SARIO
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 1:9811 NE 124TH ST APT 405
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3744
Mailing Address - Country:US
Mailing Address - Phone:425-444-3115
Mailing Address - Fax:
Practice Address - Street 1:13622 NE 20TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-4900
Practice Address - Country:US
Practice Address - Phone:425-444-3115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009705225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist