Provider Demographics
NPI:1982951778
Name:WILLMS, AMANDA SUSANNA (LMP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUSANNA
Last Name:WILLMS
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 1:209 S VANCOUVER ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-3221
Mailing Address - Country:US
Mailing Address - Phone:509-591-7088
Mailing Address - Fax:
Practice Address - Street 1:3400 W CLEARWATER AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-2709
Practice Address - Country:US
Practice Address - Phone:509-737-0610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60297070225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist