Provider Demographics
NPI:1336578319
Name:PREJEAN, AMBER (LMP)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:PREJEAN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:AMBER
Other - Middle Name:
Other - Last Name:MAYFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:5009 LAREDO DR
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-8359
Mailing Address - Country:US
Mailing Address - Phone:509-222-9824
Mailing Address - Fax:
Practice Address - Street 1:8503 W CLEARWATER AVE
Practice Address - Street 2:SUITE B
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-3100
Practice Address - Country:US
Practice Address - Phone:509-374-4719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-11
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA397920-00225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0320273OtherWASHINGTON STATE DEPARTMENT OF L&I