Healthcare Provider Details

I. General information

NPI: 1124782271
Provider Name (Legal Business Name): PANDORA JUSTINA LIESS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4791 W VAN GIESEN ST
WEST RICHLAND WA
99353-5085
US

IV. Provider business mailing address

57807 N SWEETWATER PR NE
BENTON CITY WA
99320-9515
US

V. Phone/Fax

Practice location:
  • Phone: 509-967-2225
  • Fax:
Mailing address:
  • Phone: 424-252-7379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number61104204
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: