Provider Demographics
NPI:1518220938
Name:SMITH, SONYA MAE (LMP)
Entity Type:Individual
Prefix:
First Name:SONYA
Middle Name:MAE
Last Name:SMITH
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 871448
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-1448
Mailing Address - Country:US
Mailing Address - Phone:907-203-0345
Mailing Address - Fax:
Practice Address - Street 1:9471 W BRASS CIR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-9202
Practice Address - Country:US
Practice Address - Phone:907-203-0345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60293148225700000X
AK111920225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist