Provider Demographics
NPI:1972831006
Name:ZIVKOVIC, LYNETTA MAE (LMP)
Entity Type:Individual
Prefix:MISS
First Name:LYNETTA
Middle Name:MAE
Last Name:ZIVKOVIC
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 1:10614 CANYON RD E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-4257
Mailing Address - Country:US
Mailing Address - Phone:253-535-6006
Mailing Address - Fax:253-535-6226
Practice Address - Street 1:10614 CANYON RD E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-4257
Practice Address - Country:US
Practice Address - Phone:253-535-6006
Practice Address - Fax:253-535-6226
Is Sole Proprietor?:No
Enumeration Date:2009-12-01
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60116101225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist