Provider Demographics
NPI:1891969788
Name:LEWIS, NICOLE (LMP, LMT, MMP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LMP, LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7408 NE 87TH CIR
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-2827
Mailing Address - Country:US
Mailing Address - Phone:360-989-0312
Mailing Address - Fax:360-567-0620
Practice Address - Street 1:2402 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3229
Practice Address - Country:US
Practice Address - Phone:360-989-0312
Practice Address - Fax:360-567-0620
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2013-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA24601225700000X
OR15323225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist