Provider Demographics
NPI:1952692055
Name:CROTEAU BAKER, NICHOLE L (LMP)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:L
Last Name:CROTEAU BAKER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:L
Other - Last Name:CROTEAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:12260 ROSEBERG AVE S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98168-2361
Mailing Address - Country:US
Mailing Address - Phone:406-579-4992
Mailing Address - Fax:
Practice Address - Street 1:12260 ROSEBERG AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98168-2361
Practice Address - Country:US
Practice Address - Phone:406-579-4992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60197884225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist