Provider Demographics
NPI:1255665428
Name:LOPEZ, CONNIE DANIELLE (LMP)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:DANIELLE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:C.
Other - Middle Name:DANIELLE
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:201 SW 5TH PL
Mailing Address - Street 2:M 201
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-5834
Mailing Address - Country:US
Mailing Address - Phone:832-613-3845
Mailing Address - Fax:
Practice Address - Street 1:365 RENTON CENTER WAY SW
Practice Address - Street 2:SUITE F
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2324
Practice Address - Country:US
Practice Address - Phone:425-226-7061
Practice Address - Fax:425-226-7063
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60092681225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA 60092681OtherLMP