Provider Demographics
NPI:1700910320
Name:JAVELLANA, LYRLENE KQM (LMP)
Entity type:Individual
Prefix:MRS
First Name:LYRLENE
Middle Name:KQM
Last Name:JAVELLANA
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 1:28704 235TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-3315
Mailing Address - Country:US
Mailing Address - Phone:206-799-9029
Mailing Address - Fax:253-852-3913
Practice Address - Street 1:1042 W JAMES ST
Practice Address - Street 2:SUITE NO 101
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-4606
Practice Address - Country:US
Practice Address - Phone:253-852-3770
Practice Address - Fax:253-852-3913
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017760225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA91792822OtherEMPLOYER ID NUMBER
WAMA00017760OtherSTATE LICENSE - MASSAGE
WA0192232OtherL&I PROVIDER NUMBER