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General NPI Number Information
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NPI Number | 1932680089
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Entity Type | Individual
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Provider Name | SAMDAP VANNA LY MT
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Gender | Male
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Dates
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Enumeration Date | 08/27/2018
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Last Update Date | 08/27/2018
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Provider Practice Location Address
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Address Line | 916 NE 65TH ST
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City | SEATTLE
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State | WA
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Zip | 98115-5542
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Country | US
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Telephone | 206-267-0863
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Fax |
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Provider Business Mailing Address
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Address Line | 4424 S CAMANO PL
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City | SEATTLE
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State | WA
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Zip | 98118-4627
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 60880040
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License Number State | WA
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