Provider Demographics
NPI:1194932046
Name:BOYLAN, MICHELLE ANGELA (LMP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANGELA
Last Name:BOYLAN
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 1:7824 BOX ELDER DR SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98512-2327
Mailing Address - Country:US
Mailing Address - Phone:360-280-5359
Mailing Address - Fax:360-357-4880
Practice Address - Street 1:1820 BLACK LAKE BLVD SW
Practice Address - Street 2:#103
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98512-5619
Practice Address - Country:US
Practice Address - Phone:360-943-7665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013589225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist