Healthcare Provider Details

I. General information

NPI: 1649358573
Provider Name (Legal Business Name): NANCY KRISTINE HALLER GCFP NCMMT LMP MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/31/2023
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 S 219TH ST APT 8
DES MOINES WA
98198-6364
US

IV. Provider business mailing address

821 S 219TH ST APT 8
DES MOINES WA
98198-6364
US

V. Phone/Fax

Practice location:
  • Phone: 425-282-0406
  • Fax: 206-824-7378
Mailing address:
  • Phone: 425-282-0406
  • Fax: 206-824-7378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberGCFP1653
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number1653
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMA00008877
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberNCMMT0019
License Number StateNC
# 5
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00008877
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: