Provider Demographics
NPI:1871586073
Name:SMITH, NICOLE M (LMP)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:BLUNK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:PO BOX 731269
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-0060
Mailing Address - Country:US
Mailing Address - Phone:253-840-6448
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:17650 140TH AVE SE
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-6814
Practice Address - Country:US
Practice Address - Phone:425-430-0700
Practice Address - Fax:425-430-0710
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010064225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4324SMOtherREGENCE BS
WA8930149OtherCRIME VICTIMS
WA181042OtherDEPT OF L&I