=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235672882
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRA MARIE FORKNER LMP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2016
-----------------------------------------------------
Last Update Date | 02/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1202 S. 2ND STREET SUITE E
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-610-1089
-----------------------------------------------------
Fax | 360-989-1197
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17360 RED HAWK CT
-----------------------------------------------------
City | MOUNT VERNON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98274-7797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-610-1089
-----------------------------------------------------
Fax | 360-989-1197
-----------------------------------------------------
=====================================================
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 | MA60644252
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------