Provider Demographics
NPI:1508257825
Name:MAGTANONG, DIANA-JEAN (LMP)
Entity Type:Individual
Prefix:
First Name:DIANA-JEAN
Middle Name:
Last Name:MAGTANONG
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:DIANA JEAN
Other - Middle Name:VIANZON
Other - Last Name:MAGTANONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:24505 183RD CT SE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-5323
Mailing Address - Country:US
Mailing Address - Phone:206-605-3821
Mailing Address - Fax:
Practice Address - Street 1:11014 SE 192ND ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-7432
Practice Address - Country:US
Practice Address - Phone:206-605-3821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60534651225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist