Provider Demographics
NPI:1437495918
Name:BAKER, NICOLE (LMP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BAKER
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 1:1233 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-2555
Mailing Address - Country:US
Mailing Address - Phone:360-359-8957
Mailing Address - Fax:
Practice Address - Street 1:2505 OLYMPIC HWY N
Practice Address - Street 2:STE 140
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2974
Practice Address - Country:US
Practice Address - Phone:360-427-3189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-02
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60233501225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist