Provider Demographics
NPI:1891992301
Name:FICKEL, GAYLA (LMP)
Entity Type:Individual
Prefix:
First Name:GAYLA
Middle Name:
Last Name:FICKEL
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 1:2352 HAWK DR
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2673
Mailing Address - Country:US
Mailing Address - Phone:509-522-4567
Mailing Address - Fax:509-522-4567
Practice Address - Street 1:2316 EASTGATE ST STE 110
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-1576
Practice Address - Country:US
Practice Address - Phone:509-522-4567
Practice Address - Fax:509-522-4567
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015438225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist