Provider Demographics
NPI:1679790851
Name:FUNSETH, ANITA L (LMP)
Entity Type:Individual
Prefix:MS
First Name:ANITA
Middle Name:L
Last Name:FUNSETH
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 1:2527 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4364
Mailing Address - Country:US
Mailing Address - Phone:360-414-1386
Mailing Address - Fax:
Practice Address - Street 1:1318 WASHINGTON WAY STE B
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3974
Practice Address - Country:US
Practice Address - Phone:360-425-8909
Practice Address - Fax:360-425-6905
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009138225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA188330OtherDEPT OF LABOR & INDS.