Healthcare Provider Details

I. General information

NPI: 1215361605
Provider Name (Legal Business Name): AMANDA CHANTEL ULLOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 08/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11801 NE 160TH ST SUITE D
BOTHELL WA
98011-4106
US

IV. Provider business mailing address

PO BOX 2837
WOODINVILLE WA
98072-2837
US

V. Phone/Fax

Practice location:
  • Phone: 206-850-6692
  • Fax:
Mailing address:
  • Phone: 206-850-6692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number00024803
License Number StateWA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: