Provider Demographics
NPI:1982836748
Name:THROCKMORTON, TIFFANY (LMP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:THROCKMORTON
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 1:20 E POPLAR ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3099
Mailing Address - Country:US
Mailing Address - Phone:509-527-1156
Mailing Address - Fax:509-522-4933
Practice Address - Street 1:20 E POPLAR ST
Practice Address - Street 2:SUITE 206
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3099
Practice Address - Country:US
Practice Address - Phone:509-527-1156
Practice Address - Fax:509-522-4933
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60065987225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist