Healthcare Provider Details

I. General information

NPI: 1437102977
Provider Name (Legal Business Name): ELIZABETH A POTTORFF LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 GRANT RD
EAST WENATCHEE WA
98802-5243
US

IV. Provider business mailing address

1120 GRANT RD
EAST WENATCHEE WA
98802-5243
US

V. Phone/Fax

Practice location:
  • Phone: 509-884-7163
  • Fax: 509-884-2363
Mailing address:
  • Phone: 509-884-7163
  • Fax: 509-884-2363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00022464
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: