Provider Demographics
NPI:1952709941
Name:KOENIG, CHERYL DAWN (LMP)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:DAWN
Last Name:KOENIG
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 121
Mailing Address - Street 2:
Mailing Address - City:JOYCE
Mailing Address - State:WA
Mailing Address - Zip Code:98343-0121
Mailing Address - Country:US
Mailing Address - Phone:309-258-1187
Mailing Address - Fax:
Practice Address - Street 1:118 N LIBERTY ST
Practice Address - Street 2:APT A
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4322
Practice Address - Country:US
Practice Address - Phone:360-457-7379
Practice Address - Fax:360-457-8717
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60471828172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA 60471828OtherMASSAGE THERAPY