Provider Demographics
NPI:1104110568
Name:LINDBERG, CONNIE RENEE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:RENEE
Last Name:LINDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:RENEE
Other - Last Name:LINDBERG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:8823 CANYON RD E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-6300
Mailing Address - Country:US
Mailing Address - Phone:253-446-6471
Mailing Address - Fax:253-446-7042
Practice Address - Street 1:10611 CANYON RD E # 167
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-4256
Practice Address - Country:US
Practice Address - Phone:253-254-9093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020294172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA#MA00020294OtherMASSAGE PRACTITIONER LICENSE