Healthcare Provider Details

I. General information

NPI: 1255537585
Provider Name (Legal Business Name): MELISSA ANN PETERSEN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2007
Last Update Date: 07/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3217 MERIDIAN AVE E
EDGEWOOD WA
98371
US

IV. Provider business mailing address

3217 MERIDIAN AVE E
EDGEWOOD WA
98371-2613
US

V. Phone/Fax

Practice location:
  • Phone: 253-927-5905
  • Fax: 253-321-0219
Mailing address:
  • Phone: 253-927-5905
  • Fax: 253-321-0219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00020445
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: