Provider Demographics
NPI:1639810955
Name:GONZALES, WENDY NICOLE (LMT)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:NICOLE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 NE WASHINGTON AVE APT E
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2614
Mailing Address - Country:US
Mailing Address - Phone:360-878-4740
Mailing Address - Fax:
Practice Address - Street 1:500 W MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-4252
Practice Address - Country:US
Practice Address - Phone:360-623-1214
Practice Address - Fax:360-623-1215
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-02
Last Update Date:2022-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60430621225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty