Provider Demographics
NPI:1780736793
Name:GOELLNER, VONDA L (LMP LICENSE MASSAGE)
Entity type:Individual
Prefix:MRS
First Name:VONDA
Middle Name:L
Last Name:GOELLNER
Suffix:
Gender:F
Credentials:LMP LICENSE MASSAGE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 PEARL PL
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901
Mailing Address - Country:US
Mailing Address - Phone:509-576-8969
Mailing Address - Fax:509-965-3594
Practice Address - Street 1:3909 CASTLEVALE RD
Practice Address - Street 2:STE 300
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902
Practice Address - Country:US
Practice Address - Phone:509-965-5852
Practice Address - Fax:509-965-3594
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
116432OtherL AND I
G09402OtherREGENCE BLUE SHIELD