Provider Demographics
NPI:1740511013
Name:EDISON, NANCY LARAINE (MASSAGE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:LARAINE
Last Name:EDISON
Suffix:
Gender:F
Credentials:MASSAGE PRACTITIONER
Other - Prefix:MRS
Other - First Name:NANCY
Other - Middle Name:LARAINE
Other - Last Name:EDISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MASSAGE PRACTITIONER
Mailing Address - Street 1:PO BOX 1084
Mailing Address - Street 2:
Mailing Address - City:TUMTUM
Mailing Address - State:WA
Mailing Address - Zip Code:99034-1084
Mailing Address - Country:US
Mailing Address - Phone:509-991-1946
Mailing Address - Fax:
Practice Address - Street 1:1625 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-5620
Practice Address - Country:US
Practice Address - Phone:509-991-1946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00001939225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist