Healthcare Provider Details

I. General information

NPI: 1235779919
Provider Name (Legal Business Name): MS. LAURA ELIZABETH CHURCH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2020
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10021 HOLMAN RD NW
SEATTLE WA
98177-4920
US

IV. Provider business mailing address

419 19TH AVE E APT 7
SEATTLE WA
98112-5344
US

V. Phone/Fax

Practice location:
  • Phone: 206-632-8300
  • Fax:
Mailing address:
  • Phone: 910-274-4585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60964116
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: