MEDICARE: NANCY CANYON LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker	MA8493
2	174400000X	Specialist	MA8493

General Provider Information

NPI Number	:	1295164945
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY CANYON LMP

Provider Business Mailing Address
First Line	:	910 HARRIS AVE # A206
Second Line	:
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-7008
Country	:	US
Telephone Number	:	360-710-7139
Fax Number	:

Provider Business Practice Location Address
First Line	:	907 HARRIS AVE STE 203
Second Line	:
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-7005
Country	:	US
Telephone Number	:	360-710-7139
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2013
Last Update Date	:	11/04/2013

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Directions to “ NANCY CANYON LMP” Practice Location

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