1336447879 NPI number — MS. TESSA RENEE YARBROUGH LMP

Table of content: MS. TESSA RENEE YARBROUGH LMP (NPI 1336447879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336447879 NPI number — MS. TESSA RENEE YARBROUGH LMP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YARBROUGH
Provider First Name:
TESSA
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LMP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336447879
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5702 NE GAMBLEWOOD RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98346-9557
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-710-8637
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3500 NW BUCKLIN HILL RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SILVERDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98383-8503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-698-0836
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  60192666 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 60192666 . This is a "WASHINGTON STATE DEPARTMENT OF HEALTH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0289955556 . This is a "AMERICAN MASSAGE THERAPY ASSOCIATION" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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