Healthcare Provider Details

I. General information

NPI: 1134349871
Provider Name (Legal Business Name): INGRID MARY MUSSON LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 COLWELL STREET
PORT HADLOCK WA
98339
US

IV. Provider business mailing address

PO BOX 897
PORT HADLOCK WA
98339
US

V. Phone/Fax

Practice location:
  • Phone: 360-385-9310
  • Fax: 360-379-8826
Mailing address:
  • Phone: 360-385-9310
  • Fax: 360-379-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00012792
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: