Provider Demographics
NPI:1467518944
Name:MCCOWAN, NICOLE R (MASSAGE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:MCCOWAN
Suffix:
Gender:F
Credentials:MASSAGE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4407
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98501-0407
Mailing Address - Country:US
Mailing Address - Phone:360-943-7665
Mailing Address - Fax:360-357-4880
Practice Address - Street 1:1820 BLACK LAKE BLVD SW
Practice Address - Street 2:SUITE 103
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98512-5619
Practice Address - Country:US
Practice Address - Phone:360-943-7665
Practice Address - Fax:360-357-4880
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011293174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist