Provider Demographics
NPI:1851638530
Name:FANNING, MARIE (LMP)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:FANNING
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 1:25003 114TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-6567
Mailing Address - Country:US
Mailing Address - Phone:253-854-2543
Mailing Address - Fax:
Practice Address - Street 1:25003 114TH AVE SE
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-6567
Practice Address - Country:US
Practice Address - Phone:253-854-2543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60296221225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist