MEDICARE: AMANDA SUSANNA WILLMS L.M.P.

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	MA60297070	WA

General Provider Information

NPI Number	:	1982951778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA SUSANNA WILLMS L.M.P.

Provider Business Mailing Address
First Line	:	209 S VANCOUVER ST
Second Line	:
City	:	KENNEWICK
State	:	WA
Zip	:	99336-3221
Country	:	US
Telephone Number	:	509-591-7088
Fax Number	:

Provider Business Practice Location Address
First Line	:	3400 W CLEARWATER AVE
Second Line	:	SUITE 5
City	:	KENNEWICK
State	:	WA
Zip	:	99336-2709
Country	:	US
Telephone Number	:	509-737-0610
Fax Number	:

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

Provider Enumeration Date	:	08/10/2012
Last Update Date	:	08/10/2012

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