Provider Demographics
NPI:1598187809
Name:IRVINE, LINDASUE
Entity Type:Individual
Prefix:
First Name:LINDASUE
Middle Name:
Last Name:IRVINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65709 NORTH 43RD PRNW
Mailing Address - Street 2:
Mailing Address - City:BENTON CITY
Mailing Address - State:WA
Mailing Address - Zip Code:99320-6601
Mailing Address - Country:US
Mailing Address - Phone:253-686-6398
Mailing Address - Fax:
Practice Address - Street 1:65709 NORTH 43RD PRNW
Practice Address - Street 2:
Practice Address - City:BENTON CITY
Practice Address - State:WA
Practice Address - Zip Code:99320-6601
Practice Address - Country:US
Practice Address - Phone:253-686-6398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA# 60366371225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist