Healthcare Provider Details

I. General information

NPI: 1912661737
Provider Name (Legal Business Name): LAWANA BALLANCE MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10324 CANYON RD E STE 203
PUYALLUP WA
98373-1013
US

IV. Provider business mailing address

10324 CANYON RD E STE 203
PUYALLUP WA
98373-1013
US

V. Phone/Fax

Practice location:
  • Phone: 253-471-2727
  • Fax: 253-471-2730
Mailing address:
  • Phone: 253-471-2727
  • Fax: 253-471-2730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number61203985
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: