MEDICARE: PETRONELLA JOHANNA KAANDORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA.60239250	WA

General Provider Information

NPI Number	:	1437426400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETRONELLA JOHANNA KAANDORP

Provider Business Mailing Address
First Line	:	6731 27TH AVE NW
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98117-5904
Country	:	US
Telephone Number	:	206-501-0937
Fax Number	:

Provider Business Practice Location Address
First Line	:	6731 27TH AVE NW
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98117-5904
Country	:	US
Telephone Number	:	206-501-0937
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2011
Last Update Date	:	11/18/2011

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