Provider Demographics
NPI:1518362755
Name:NESARY, AMANDA LORRAINE (LMP)
Entity Type:Individual
Prefix:MISS
First Name:AMANDA
Middle Name:LORRAINE
Last Name:NESARY
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 1:1902 S 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98903-1016
Mailing Address - Country:US
Mailing Address - Phone:509-910-1250
Mailing Address - Fax:
Practice Address - Street 1:1108 MEADE AVE
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-1367
Practice Address - Country:US
Practice Address - Phone:509-781-6235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60355874225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist