Provider Demographics
NPI:1740483155
Name:VAN NESS, MAURA (MARY) ANGELA (LMP)
Entity type:Individual
Prefix:MS
First Name:MAURA (MARY)
Middle Name:ANGELA
Last Name:VAN NESS
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:PO BOX 866
Mailing Address - Street 2:
Mailing Address - City:DUVALL
Mailing Address - State:WA
Mailing Address - Zip Code:98019-0866
Mailing Address - Country:US
Mailing Address - Phone:425-788-9249
Mailing Address - Fax:425-788-7319
Practice Address - Street 1:27516 NE 116TH ST
Practice Address - Street 2:
Practice Address - City:DUVALL
Practice Address - State:WA
Practice Address - Zip Code:98019-9609
Practice Address - Country:US
Practice Address - Phone:425-788-9249
Practice Address - Fax:425-788-7319
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA MASSAGELIC#007892171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor