Provider Demographics
NPI:1114390168
Name:PRIDDY, CARLA BONE (LMP)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:BONE
Last Name:PRIDDY
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 NW 118TH CIRCLE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685
Mailing Address - Country:US
Mailing Address - Phone:360-836-5317
Mailing Address - Fax:
Practice Address - Street 1:12504 NW 36TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2227
Practice Address - Country:US
Practice Address - Phone:360-836-5317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60479768225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist