Provider Demographics
NPI:1659709020
Name:SPANN, CODY WETMORE (LMP)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:WETMORE
Last Name:SPANN
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 1:2413 PACIFIC AVE SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-2087
Mailing Address - Country:US
Mailing Address - Phone:253-951-1213
Mailing Address - Fax:360-539-7729
Practice Address - Street 1:2413 PACIFIC AVE SE
Practice Address - Street 2:SUITE D
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-2087
Practice Address - Country:US
Practice Address - Phone:253-951-1213
Practice Address - Fax:360-539-7729
Is Sole Proprietor?:No
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60401812225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist