Provider Demographics
NPI:1578837977
Name:POLLEY, MAGNOLIA MAY (LMP)
Entity Type:Individual
Prefix:
First Name:MAGNOLIA
Middle Name:MAY
Last Name:POLLEY
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:PO BOX 1890
Mailing Address - Street 2:
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816-1890
Mailing Address - Country:US
Mailing Address - Phone:509-888-5477
Mailing Address - Fax:509-888-5352
Practice Address - Street 1:136 E JOHNSON AVE, STE 1
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816
Practice Address - Country:US
Practice Address - Phone:509-888-5477
Practice Address - Fax:509-888-5352
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017085225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist