Healthcare Provider Details

I. General information

NPI: 1508202904
Provider Name (Legal Business Name): MELINDA KAY CHANTRY LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396875 HIGHWAY 20
CUSICK WA
99119-9604
US

IV. Provider business mailing address

396875 HIGHWAY 20
CUSICK WA
99119-9604
US

V. Phone/Fax

Practice location:
  • Phone: 509-936-1869
  • Fax:
Mailing address:
  • Phone: 509-936-1869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 6033581
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: