Provider Demographics
NPI:1508182775
Name:RYE, CONNIE L (LMP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:RYE
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 1:2509 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2621
Mailing Address - Country:US
Mailing Address - Phone:206-883-7799
Mailing Address - Fax:
Practice Address - Street 1:9873 BRIDGEPORT WAY SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-2895
Practice Address - Country:US
Practice Address - Phone:206-883-7799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00007372172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA602050322OtherDEPARTMENT OF LICENSING (UBI)