Healthcare Provider Details

I. General information

NPI: 1982960076
Provider Name (Legal Business Name): MICHELINA DE SIMONE LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11419 19TH AVE SE STE A109
EVERETT WA
98208-5120
US

IV. Provider business mailing address

326 134TH PL SW
EVERETT WA
98208-6823
US

V. Phone/Fax

Practice location:
  • Phone: 425-379-2556
  • Fax:
Mailing address:
  • Phone: 425-931-1657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60168934
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: