Provider Demographics
NPI:1558814558
Name:PRUETT, TONYA (LMP)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:PRUETT
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 1:403 NE 319TH AVE
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-8209
Mailing Address - Country:US
Mailing Address - Phone:309-241-2503
Mailing Address - Fax:
Practice Address - Street 1:3307 EVERGREEN WAY
Practice Address - Street 2:#601
Practice Address - City:WASHOUGAL
Practice Address - State:WA
Practice Address - Zip Code:98671-2062
Practice Address - Country:US
Practice Address - Phone:360-835-9911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60674370225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist