Provider Demographics
NPI:1982776670
Name:STEWART, KEELY NICOLE (LMP)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:NICOLE
Last Name:STEWART
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 1:16923 96TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-1937
Mailing Address - Country:US
Mailing Address - Phone:425-485-7507
Mailing Address - Fax:425-483-7332
Practice Address - Street 1:16923 96TH AVE NE
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-1937
Practice Address - Country:US
Practice Address - Phone:425-485-7507
Practice Address - Fax:425-483-7332
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA17772225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA17772OtherLICENSE NUMBER