Provider Demographics
NPI:1568653319
Name:CANNON, MELISSA JOAN (LMP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JOAN
Last Name:CANNON
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 1:836 NW 63RD ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98107-2212
Mailing Address - Country:US
Mailing Address - Phone:206-697-6745
Mailing Address - Fax:
Practice Address - Street 1:101 E MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1519
Practice Address - Country:US
Practice Address - Phone:360-863-0642
Practice Address - Fax:360-794-7236
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021163225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist