Healthcare Provider Details

I. General information

NPI: 1861635252
Provider Name (Legal Business Name): KATIE JOY WAKIN LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2009
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

1901 MERRILL CREEK PKWY APT M307
EVERETT WA
98203-5887
US

V. Phone/Fax

Practice location:
  • Phone: 425-355-3739
  • Fax: 425-514-8353
Mailing address:
  • Phone: 253-209-3142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00022602
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: