Provider Demographics
NPI:1417624404
Name:SUTTIPUI, MUEANFAN
Entity Type:Individual
Prefix:
First Name:MUEANFAN
Middle Name:
Last Name:SUTTIPUI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:980 FALCON RD
Mailing Address - Street 2:
Mailing Address - City:CAMANO ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98282-8411
Mailing Address - Country:US
Mailing Address - Phone:425-220-3589
Mailing Address - Fax:
Practice Address - Street 1:7207 265TH ST NW STE 102
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-6274
Practice Address - Country:US
Practice Address - Phone:360-629-6544
Practice Address - Fax:360-629-4520
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61162304225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist