Provider Demographics
NPI:1578831293
Name:VITRUK, INNA (LMP)
Entity Type:Individual
Prefix:
First Name:INNA
Middle Name:
Last Name:VITRUK
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 1:1010 S 336TH ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6385
Mailing Address - Country:US
Mailing Address - Phone:253-874-9001
Mailing Address - Fax:253-874-9051
Practice Address - Street 1:1010 S 336TH ST
Practice Address - Street 2:SUITE 120
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6385
Practice Address - Country:US
Practice Address - Phone:253-874-9001
Practice Address - Fax:253-874-9051
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA989840225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist