MEDICARE: CHERYL DAWN KOENIG LMP

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	172V00000X	Community Health Worker	MA60471828	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA 60471828	OTHER	WA	MASSAGE THERAPY

General Provider Information

NPI Number	:	1952709941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERYL DAWN KOENIG LMP

Provider Business Mailing Address
First Line	:	PO BOX 121
Second Line	:
City	:	JOYCE
State	:	WA
Zip	:	98343-0121
Country	:	US
Telephone Number	:	309-258-1187
Fax Number	:

Provider Business Practice Location Address
First Line	:	118 N LIBERTY ST
Second Line	:	APT A
City	:	PORT ANGELES
State	:	WA
Zip	:	98362-4322
Country	:	US
Telephone Number	:	360-457-7379
Fax Number	:	360-457-8717

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

Provider Enumeration Date	:	12/08/2014
Last Update Date	:	12/08/2014

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