Provider Demographics
NPI:1942438171
Name:PROCTOR, MICHELLE LYN (LMP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYN
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3291 WILLMS RD
Mailing Address - Street 2:
Mailing Address - City:ELK
Mailing Address - State:WA
Mailing Address - Zip Code:99009-9553
Mailing Address - Country:US
Mailing Address - Phone:509-863-4523
Mailing Address - Fax:
Practice Address - Street 1:3299 WILLMS RD
Practice Address - Street 2:
Practice Address - City:ELK
Practice Address - State:WA
Practice Address - Zip Code:99009-9553
Practice Address - Country:US
Practice Address - Phone:509-863-4523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021317225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist