MEDICARE: NICOLE LEE BRAITHWAITE LMP, CPMT

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	225700000X	Massage Therapist	MA 60059360	WA

General Provider Information

NPI Number	:	1659527810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE LEE BRAITHWAITE LMP, CPMT

Provider Business Mailing Address
First Line	:	43411 SE 172ND PL
Second Line	:
City	:	NORTH BEND
State	:	WA
Zip	:	98045-9660
Country	:	US
Telephone Number	:	425-301-8611
Fax Number	:

Provider Business Practice Location Address
First Line	:	213 BENDIGO BLVD N
Second Line	:
City	:	NORTH BEND
State	:	WA
Zip	:	98045-8259
Country	:	US
Telephone Number	:	425-301-8611
Fax Number	:

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

Provider Enumeration Date	:	08/07/2008
Last Update Date	:	09/28/2009

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