Provider Demographics
NPI:1508377961
Name:MORENO, PRYSILLA (ND, LAC)
Entity Type:Individual
Prefix:
First Name:PRYSILLA
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 SW CAMPUS DR # 623
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-6473
Mailing Address - Country:US
Mailing Address - Phone:253-431-4144
Mailing Address - Fax:
Practice Address - Street 1:720 S 320TH ST STE E
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5254
Practice Address - Country:US
Practice Address - Phone:253-237-4704
Practice Address - Fax:833-471-4454
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175F00000X, 171100000X
WAMA60791810225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171100000XOther Service ProvidersAcupuncturist