Provider Demographics
NPI:1487618054
Name:MABRA, VANESSA K (LMP)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:K
Last Name:MABRA
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:K
Other - Last Name:MCCLURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:PO BOX 731269
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-0060
Mailing Address - Country:US
Mailing Address - Phone:253-840-2313
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:22739 SE 29TH ST
Practice Address - Street 2:
Practice Address - City:SAMMAMISH
Practice Address - State:WA
Practice Address - Zip Code:98075-9532
Practice Address - Country:US
Practice Address - Phone:425-392-4010
Practice Address - Fax:425-392-4011
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011269225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8933010OtherCRIME VICTIMS
WA164121OtherDEPT OF LABOR AND INDUSTR
WA9875MCOtherREGENCE BLUE SHIELD