Healthcare Provider Details

I. General information

NPI: 1023757366
Provider Name (Legal Business Name): TARA LYN JEAN FLETCHER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1427 JEFFERSON AVE STE 202
ENUMCLAW WA
98022-3649
US

IV. Provider business mailing address

27622 SE 401ST ST
ENUMCLAW WA
98022-9722
US

V. Phone/Fax

Practice location:
  • Phone: 360-388-0409
  • Fax:
Mailing address:
  • Phone: 360-388-0409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA61313051
License Number StateWA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: