Provider Demographics
NPI:1548397342
Name:WALSH, NICOLE MICHELLE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MICHELLE
Last Name:WALSH
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 1:1318 138TH ST SE
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-5505
Mailing Address - Country:US
Mailing Address - Phone:206-276-2265
Mailing Address - Fax:425-385-2042
Practice Address - Street 1:1318 138TH ST SE
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-5505
Practice Address - Country:US
Practice Address - Phone:206-276-2265
Practice Address - Fax:425-385-2042
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00005369174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist