Provider Demographics
NPI:1750316352
Name:WICKWIRE, JULIE ANN (LMP)
Entity type:Individual
Prefix:MISS
First Name:JULIE
Middle Name:ANN
Last Name:WICKWIRE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:19201 108TH AVE SE
Mailing Address - Street 2:#101
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-7379
Mailing Address - Country:US
Mailing Address - Phone:253-859-6441
Mailing Address - Fax:253-859-9437
Practice Address - Street 1:19201 108TH AVE SE
Practice Address - Street 2:#101
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-7379
Practice Address - Country:US
Practice Address - Phone:253-859-6441
Practice Address - Fax:253-859-9437
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00007494225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4705WIOtherREGENCE BLUESHIELD
WA0162510OtherLABOR AND INDUSTRIES