Provider Demographics
NPI:1639769938
Name:REYNA MORA, ANJELICA (MA61118530)
Entity Type:Individual
Prefix:
First Name:ANJELICA
Middle Name:
Last Name:REYNA MORA
Suffix:
Gender:F
Credentials:MA61118530
Other - Prefix:
Other - First Name:ANJELICA
Other - Middle Name:
Other - Last Name:REYNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3908 CREEKSIDE LOOP STE 110
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-4858
Mailing Address - Country:US
Mailing Address - Phone:509-985-0714
Mailing Address - Fax:509-248-5356
Practice Address - Street 1:3908 CREEKSIDE LOOP STE 110
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-4858
Practice Address - Country:US
Practice Address - Phone:509-985-0714
Practice Address - Fax:509-248-5356
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61118530225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist