Provider Demographics
NPI:1629393061
Name:TENNER, MANDARA (LMP)
Entity Type:Individual
Prefix:
First Name:MANDARA
Middle Name:
Last Name:TENNER
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 9091
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99209-9091
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3022 E 57TH AVE
Practice Address - Street 2:SUITE 14
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-7033
Practice Address - Country:US
Practice Address - Phone:509-481-5294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-29
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60123473225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist