=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528576477
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINA MARIE PEZZINO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2018
-----------------------------------------------------
Last Update Date | 01/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10575 NE 12TH ST STE 17
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-4362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-292-7888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36110 SE TURNBERRY ST
-----------------------------------------------------
City | SNOQUALMIE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98065-8718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-280-5610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | MA60651988
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------