Provider Demographics
NPI:1124782271
Name:LIESS, PANDORA JUSTINA
Entity type:Individual
Prefix:
First Name:PANDORA
Middle Name:JUSTINA
Last Name:LIESS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57807 N SWEETWATER PR NE
Mailing Address - Street 2:
Mailing Address - City:BENTON CITY
Mailing Address - State:WA
Mailing Address - Zip Code:99320-9515
Mailing Address - Country:US
Mailing Address - Phone:424-252-7379
Mailing Address - Fax:
Practice Address - Street 1:4791 W VAN GIESEN ST
Practice Address - Street 2:
Practice Address - City:WEST RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99353-5085
Practice Address - Country:US
Practice Address - Phone:509-967-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61104204225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA61104204OtherMASSAGE THERAPIST