Provider Demographics
NPI:1891262531
Name:WALTERS, VANESSA DIANE (LMT)
Entity Type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:DIANE
Last Name:WALTERS
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 1:2911 199TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:LAKE TAPPS
Mailing Address - State:WA
Mailing Address - Zip Code:98391-9067
Mailing Address - Country:US
Mailing Address - Phone:206-430-0020
Mailing Address - Fax:
Practice Address - Street 1:4009 BRIDGEPORT WAY W STE E-7
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4326
Practice Address - Country:US
Practice Address - Phone:253-237-3331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60863848225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist