Healthcare Provider Details

I. General information

NPI: 1134473085
Provider Name (Legal Business Name): LACEY DAWN SIMMONS LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3209 E 57TH AVE STE F
SPOKANE WA
99223-7040
US

IV. Provider business mailing address

1318 N STOUT RD
SPOKANE VALLEY WA
99206-4086
US

V. Phone/Fax

Practice location:
  • Phone: 509-448-9398
  • Fax:
Mailing address:
  • Phone: 509-572-0205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 00018110
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: