Provider Demographics
NPI:1023301306
Name:THIESSEN, TAMMY RENA (LMP)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:RENA
Last Name:THIESSEN
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:P.O. BOX 2072
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98041
Mailing Address - Country:US
Mailing Address - Phone:425-806-5525
Mailing Address - Fax:425-806-3915
Practice Address - Street 1:10117 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011
Practice Address - Country:US
Practice Address - Phone:425-806-5525
Practice Address - Fax:425-806-3915
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60224600225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist