Healthcare Provider Details

I. General information

NPI: 1982776670
Provider Name (Legal Business Name): KEELY NICOLE STEWART LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16923 96TH AVE NE
BOTHELL WA
98011-1937
US

IV. Provider business mailing address

16923 96TH AVE NE
BOTHELL WA
98011-1937
US

V. Phone/Fax

Practice location:
  • Phone: 425-485-7507
  • Fax: 425-483-7332
Mailing address:
  • Phone: 425-485-7507
  • Fax: 425-483-7332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA17772
License Number StateWA

VII. Legacy identifiers

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

# 1
IdentifierMA17772
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerLICENSE NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: