Provider Demographics
NPI:1467742510
Name:WAMMOCK, MICHELLE LYNNE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:LYNNE
Last Name:WAMMOCK
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNNE
Other - Last Name:SODERLIND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:211 W HILL ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1404
Mailing Address - Country:US
Mailing Address - Phone:360-794-6620
Mailing Address - Fax:
Practice Address - Street 1:211 W HILL ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1404
Practice Address - Country:US
Practice Address - Phone:360-794-6620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60144713225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist