Healthcare Provider Details

I. General information

NPI: 1437428927
Provider Name (Legal Business Name): PAMELA MARIE WEIDER LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2011
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 E 8TH ST STE D
PORT ANGELES WA
98362-6251
US

IV. Provider business mailing address

603 E 8TH ST STE D
PORT ANGELES WA
98362-6251
US

V. Phone/Fax

Practice location:
  • Phone: 360-452-2934
  • Fax: 360-452-7468
Mailing address:
  • Phone: 360-452-2934
  • Fax: 360-452-7468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60263083
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: