Healthcare Provider Details

I. General information

NPI: 1275598567
Provider Name (Legal Business Name): ANGELA GRANT LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 01/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MARKET ST NE SUITE 108
OLYMPIA WA
98501-1008
US

IV. Provider business mailing address

5210 CORPORATE CENTER LOOP SE SUITE D
LACEY WA
98503-5952
US

V. Phone/Fax

Practice location:
  • Phone: 360-754-7085
  • Fax: 360-754-3671
Mailing address:
  • Phone: 360-455-8155
  • Fax: 360-455-1655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: