Provider Demographics
NPI:1811583420
Name:PARK, JANELLE ELIZABETH (LMT)
Entity Type:Individual
Prefix:MISS
First Name:JANELLE
Middle Name:ELIZABETH
Last Name:PARK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1920 MAIN ST STE 14C
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-9472
Mailing Address - Country:US
Mailing Address - Phone:360-920-0354
Mailing Address - Fax:
Practice Address - Street 1:1920 MAIN ST STE 14C
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-9472
Practice Address - Country:US
Practice Address - Phone:360-920-0354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61104330225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA61104330OtherMASSAGE THERAPY LICENSE