Provider Demographics
NPI:1700939923
Name:PAUL, TRACE JEAN (LMP)
Entity Type:Individual
Prefix:MRS
First Name:TRACE
Middle Name:JEAN
Last Name:PAUL
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 1:1161 2ND AVE S
Mailing Address - Street 2:
Mailing Address - City:OKANOGAN
Mailing Address - State:WA
Mailing Address - Zip Code:98840-9709
Mailing Address - Country:US
Mailing Address - Phone:509-422-0630
Mailing Address - Fax:509-422-0630
Practice Address - Street 1:1161 2ND AVE S
Practice Address - Street 2:
Practice Address - City:OKANOGAN
Practice Address - State:WA
Practice Address - Zip Code:98840-9709
Practice Address - Country:US
Practice Address - Phone:509-422-0630
Practice Address - Fax:509-422-0630
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020264225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00020264OtherWA STATE LICENSE