Provider Demographics
NPI:1710329107
Name:MADDOX, FEARECIA (LMP)
Entity Type:Individual
Prefix:
First Name:FEARECIA
Middle Name:
Last Name:MADDOX
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:ROBYN
Other - Middle Name:KATHLEEN
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNA, RMT
Mailing Address - Street 1:12721 E SHANNON AVE
Mailing Address - Street 2:#C143
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1651
Mailing Address - Country:US
Mailing Address - Phone:208-290-7704
Mailing Address - Fax:
Practice Address - Street 1:12727 W 14TH AVE
Practice Address - Street 2:
Practice Address - City:AIRWAY HEIGHTS
Practice Address - State:WA
Practice Address - Zip Code:99001-9409
Practice Address - Country:US
Practice Address - Phone:509-244-4818
Practice Address - Fax:509-244-8945
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60351855225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist