Provider Demographics
NPI:1467763862
Name:CUNNINGHAM, TARA LOUISE (LMP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LOUISE
Last Name:CUNNINGHAM
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:PO BOX 851
Mailing Address - Street 2:
Mailing Address - City:RAINIER
Mailing Address - State:WA
Mailing Address - Zip Code:98576-0851
Mailing Address - Country:US
Mailing Address - Phone:360-955-0060
Mailing Address - Fax:
Practice Address - Street 1:109 SECOND ST W
Practice Address - Street 2:
Practice Address - City:RAINIER
Practice Address - State:WA
Practice Address - Zip Code:98576
Practice Address - Country:US
Practice Address - Phone:360-955-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60129897172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist