Provider Demographics
NPI:1760695142
Name:COLTOM, NANCY J (LMP)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:J
Last Name:COLTOM
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:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:CARNATION
Mailing Address - State:WA
Mailing Address - Zip Code:98014-0253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:249 MAIN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:NORTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98045
Practice Address - Country:US
Practice Address - Phone:425-466-5386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020564225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist