Healthcare Provider Details

I. General information

NPI: 1346639424
Provider Name (Legal Business Name): SUSAN LYELL LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8490 MUKILTEO SPEEDWAY
MUKILTEO WA
98275-3206
US

IV. Provider business mailing address

951 4TH ST
MUKILTEO WA
98275-1629
US

V. Phone/Fax

Practice location:
  • Phone: 206-595-7026
  • Fax:
Mailing address:
  • Phone: 206-595-7026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60400309
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: