Provider Demographics
NPI:1013300219
Name:WALLENFANG, LAUREN (MA60397425)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WALLENFANG
Suffix:
Gender:F
Credentials:MA60397425
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1365
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-4322
Mailing Address - Country:US
Mailing Address - Phone:612-246-2485
Mailing Address - Fax:
Practice Address - Street 1:660 W EVERGREEN FARM WAY
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-5097
Practice Address - Country:US
Practice Address - Phone:612-246-2485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-11
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60397425225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist