Provider Demographics
NPI:1568070076
Name:ANDRUS, MAGGIE JEAN
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:JEAN
Last Name:ANDRUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 COVENTRY LN SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-0494
Mailing Address - Country:US
Mailing Address - Phone:913-653-9881
Mailing Address - Fax:
Practice Address - Street 1:2808 COVENTRY LN SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-0494
Practice Address - Country:US
Practice Address - Phone:913-653-9881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61090868225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAWDL16B4J553BMedicaid