Provider Demographics
NPI:1760831283
Name:DIANA NELSON MASSAGE LLC
Entity type:Organization
Organization Name:DIANA NELSON MASSAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MASSAGE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMP
Authorized Official - Phone:509-301-3859
Mailing Address - Street 1:401 W MAIN ST # 105
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2837
Mailing Address - Country:US
Mailing Address - Phone:509-301-3859
Mailing Address - Fax:
Practice Address - Street 1:401 W MAIN ST # 105
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2837
Practice Address - Country:US
Practice Address - Phone:509-301-3859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIANA NELSON MASSAGE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60654108225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty