Provider Demographics
NPI:1710106471
Name:CLEVENGER, GAIL MICHELLE (LAC, LMP)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:MICHELLE
Last Name:CLEVENGER
Suffix:
Gender:F
Credentials:LAC, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22005 76TH AVE W
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-7905
Mailing Address - Country:US
Mailing Address - Phone:206-595-4512
Mailing Address - Fax:425-776-3844
Practice Address - Street 1:22005 76TH AVE W
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7905
Practice Address - Country:US
Practice Address - Phone:206-595-4512
Practice Address - Fax:425-776-3844
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011147174400000X
WAAC00002247171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No174400000XOther Service ProvidersSpecialist