Healthcare Provider Details

I. General information

NPI: 1962762302
Provider Name (Legal Business Name): OLHA V ZHUKOVSKIY LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2012
Last Update Date: 05/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11825 SE 280TH ST
KENT WA
98030-8741
US

IV. Provider business mailing address

11825 SE 280TH ST
KENT WA
98030-8741
US

V. Phone/Fax

Practice location:
  • Phone: 206-478-2824
  • Fax:
Mailing address:
  • Phone: 206-478-2824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60283782
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: