Provider Demographics
NPI:1558323634
Name:DVORAK, NIKKI LEE (LMP)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:LEE
Last Name:DVORAK
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 82
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-0082
Mailing Address - Country:US
Mailing Address - Phone:425-923-5433
Mailing Address - Fax:425-322-5004
Practice Address - Street 1:3701 COLBY AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4979
Practice Address - Country:US
Practice Address - Phone:425-923-5433
Practice Address - Fax:425-322-5004
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020416225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0143536OtherL & I
WA6978-DV-COLBY AVEOtherREGENCE