Provider Demographics
NPI:1790007797
Name:NYLUND, DWYNE A (LMP)
Entity Type:Individual
Prefix:
First Name:DWYNE
Middle Name:A
Last Name:NYLUND
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 SE 164TH AVE.
Mailing Address - Street 2:STE. 3
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684
Mailing Address - Country:US
Mailing Address - Phone:360-253-9482
Mailing Address - Fax:360-253-5366
Practice Address - Street 1:918 SE 164TH AVE.
Practice Address - Street 2:STE. 3
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684
Practice Address - Country:US
Practice Address - Phone:360-253-9482
Practice Address - Fax:360-253-5366
Is Sole Proprietor?:No
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015207225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist