Provider Demographics
NPI:1568954683
Name:PRATER, BEVERLY NICOLE (MA60862028)
Entity Type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:NICOLE
Last Name:PRATER
Suffix:
Gender:F
Credentials:MA60862028
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 MILL CREEK BLVD APT I202
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-3086
Mailing Address - Country:US
Mailing Address - Phone:360-201-6795
Mailing Address - Fax:
Practice Address - Street 1:1231 MILL CREEK BLVD APT I202
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-3086
Practice Address - Country:US
Practice Address - Phone:360-201-6795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60862028225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60862028OtherWASHINGTON DOH