Healthcare Provider Details

I. General information

NPI: 1942421474
Provider Name (Legal Business Name): DINA MARIE PLOEGMAN LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DINA MARIE CLARK

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 NW GILMAN BLVD SUITE 8
ISSAQUAH WA
98027
US

IV. Provider business mailing address

14853 SE 113TH ST
RENTON WA
98059-6007
US

V. Phone/Fax

Practice location:
  • Phone: 425-313-9222
  • Fax: 425-313-9339
Mailing address:
  • Phone: 425-531-1547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00022250
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: