Provider Demographics
NPI:1255547840
Name:BOLLENTIN, ASHLEY (LMP)
Entity type:Individual
Prefix:MISS
First Name:ASHLEY
Middle Name:
Last Name:BOLLENTIN
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 1:15420 36TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98012
Mailing Address - Country:US
Mailing Address - Phone:206-849-2616
Mailing Address - Fax:
Practice Address - Street 1:19102 NORTH CREEK PARKWAY
Practice Address - Street 2:SUITE 104
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011
Practice Address - Country:US
Practice Address - Phone:425-486-6079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022368225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist