Provider Demographics
NPI:1578776753
Name:CLARK-RIXMANN, DIEDRA FRIE (LMP)
Entity Type:Individual
Prefix:
First Name:DIEDRA
Middle Name:FRIE
Last Name:CLARK-RIXMANN
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 1:332 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-6106
Mailing Address - Country:US
Mailing Address - Phone:206-354-4301
Mailing Address - Fax:
Practice Address - Street 1:7300 E GREEN LAKE DR N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-8604
Practice Address - Country:US
Practice Address - Phone:206-354-4301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013490174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist