Provider Demographics
NPI:1952743155
Name:SULLIVAN, MICHELLE L (LMP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:LUCENA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-0005
Mailing Address - Country:US
Mailing Address - Phone:425-299-9745
Mailing Address - Fax:
Practice Address - Street 1:4322 RUCKER AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2233
Practice Address - Country:US
Practice Address - Phone:425-258-5454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60394974225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist