Healthcare Provider Details

I. General information

NPI: 1750529459
Provider Name (Legal Business Name): LACY ANNE BONEY-VANGEMERT LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11314 4TH AVE W SUITE 103
EVERETT WA
98204
US

IV. Provider business mailing address

11314 4TH AVE W SUITE 103
EVERETT WA
98204-6926
US

V. Phone/Fax

Practice location:
  • Phone: 425-355-3739
  • Fax: 425-514-8353
Mailing address:
  • Phone: 425-355-3739
  • Fax: 425-514-8353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 00022861
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: