=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083769038
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NINA R. MATTOON LMP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2007
-----------------------------------------------------
Last Update Date | 04/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3435 CALIFORNIA AVE SW STE 100A
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98116-3371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-937-4777
-----------------------------------------------------
Fax | 206-923-0093
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4123 SW KENYON ST
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98136-2332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-221-3236
-----------------------------------------------------
Fax | 206-923-0093
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA00014101
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------