Provider Demographics
NPI:1740024447
Name:FRIZELLE, AHNARAE MARIE (LMT)
Entity type:Individual
Prefix:
First Name:AHNARAE
Middle Name:MARIE
Last Name:FRIZELLE
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 1:365 MADRONA AVE SE APT B6
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6609
Mailing Address - Country:US
Mailing Address - Phone:503-851-5074
Mailing Address - Fax:
Practice Address - Street 1:3990 CHERRY AVE NE STE 103
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4888
Practice Address - Country:US
Practice Address - Phone:971-332-5916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR28375225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty