Provider Demographics
NPI:1609933092
Name:MARTIN, ADRIENNE M (LMP)
Entity Type:Individual
Prefix:MS
First Name:ADRIENNE
Middle Name:M
Last Name:MARTIN
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 1370
Mailing Address - Street 2:
Mailing Address - City:MCKENNA
Mailing Address - State:WA
Mailing Address - Zip Code:98558-1370
Mailing Address - Country:US
Mailing Address - Phone:360-400-2002
Mailing Address - Fax:360-400-2004
Practice Address - Street 1:9111 346 ST S
Practice Address - Street 2:SUITE 3
Practice Address - City:ROX
Practice Address - State:WA
Practice Address - Zip Code:98580
Practice Address - Country:US
Practice Address - Phone:360-400-2002
Practice Address - Fax:360-400-2004
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015464225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist