Provider Demographics
NPI:1790803724
Name:DOMMERMUTH, AMANDA BETH (LMP)
Entity Type:Individual
Prefix:MS
First Name:AMANDA
Middle Name:BETH
Last Name:DOMMERMUTH
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 1:2019 S 282ND PL
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-3241
Mailing Address - Country:US
Mailing Address - Phone:206-661-3401
Mailing Address - Fax:
Practice Address - Street 1:34730 PACIFIC HWY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6821
Practice Address - Country:US
Practice Address - Phone:253-874-0198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022274225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist