Healthcare Provider Details

I. General information

NPI: 1457755720
Provider Name (Legal Business Name): DIANA WURZER LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2014
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3307 EVERGREEN WAY SUITE 601
WASHOUGAL WA
98671-2062
US

IV. Provider business mailing address

3307 EVERGREEN WAY SUITE 601
WASHOUGAL WA
98671-2062
US

V. Phone/Fax

Practice location:
  • Phone: 360-835-9911
  • Fax:
Mailing address:
  • Phone: 360-835-9911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60046341
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: