Provider Demographics
NPI:1679600530
Name:LATTA, VICKIE LYNN (LMP)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:LYNN
Last Name:LATTA
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 1:5811 93RD PL NE
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-2796
Mailing Address - Country:US
Mailing Address - Phone:425-343-5257
Mailing Address - Fax:
Practice Address - Street 1:10525 STATE AVE STE 1
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98271-7216
Practice Address - Country:US
Practice Address - Phone:360-657-1262
Practice Address - Fax:360-658-4127
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016085225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist