Provider Demographics
NPI:1730136334
Name:MALMBORG OKELLEY, TYRA L (PT)
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:L
Last Name:MALMBORG OKELLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 132ND ST SE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-8999
Mailing Address - Country:US
Mailing Address - Phone:425-357-9380
Mailing Address - Fax:425-357-9382
Practice Address - Street 1:5029 EVERGREEN WAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2826
Practice Address - Country:US
Practice Address - Phone:425-252-1642
Practice Address - Fax:425-258-1824
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5028MAOtherREGENCE BLUE SHIELD
WA8385379Medicaid
WA0264717OtherDEPT OF L&I
WA8875MAOtherREGENCE BLUE SHIELD
WA2358MAOtherREGENCE BLUE SHIELD
WA4524MAOtherREGENCE BLUE SHIELD
WA5342MAOtherREGENCE BLUE SHIELD
WA911745305-98203-C007OtherTRICARE
WA0201977OtherDEPT. OF LABOR & INDUSTRY
WA0562MAOtherREGENCE
WA8542MAOtherREGENCE BLUE SHIELD
WA8935654OtherL&I CRIME VICTIMS
WA911745305-98275-A004OtherTRICARE
WA5066111OtherAETNA
WA8935654OtherL&I CRIME VICTIMS
WAG8894425Medicare PIN