Provider Demographics
NPI:1750529459
Name:BONEY-VANGEMERT, LACY ANNE (LMP)
Entity type:Individual
Prefix:MRS
First Name:LACY
Middle Name:ANNE
Last Name:BONEY-VANGEMERT
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 1:11314 4TH AVE W
Mailing Address - Street 2:SUITE 103
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-6926
Mailing Address - Country:US
Mailing Address - Phone:425-355-3739
Mailing Address - Fax:425-514-8353
Practice Address - Street 1:11314 4TH AVE W
Practice Address - Street 2:SUITE 103
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204
Practice Address - Country:US
Practice Address - Phone:425-355-3739
Practice Address - Fax:425-514-8353
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00022861225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist