Healthcare Provider Details

I. General information

NPI: 1104112077
Provider Name (Legal Business Name): MRS. MICHELLE RANAE KOENEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7859 SIDNEY RD SW
PORT ORCHARD WA
98367-7030
US

IV. Provider business mailing address

PO BOX 440
PORT ORCHARD WA
98366-0440
US

V. Phone/Fax

Practice location:
  • Phone: 360-876-0170
  • Fax:
Mailing address:
  • Phone: 360-876-0170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00007058
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: