Provider Demographics
NPI:1215054432
Name:VANWAGNER, TARA LYN (LMP)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LYN
Last Name:VANWAGNER
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 1:1816 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-1336
Mailing Address - Country:US
Mailing Address - Phone:509-860-3741
Mailing Address - Fax:
Practice Address - Street 1:1601 N WENATCHEE AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-1158
Practice Address - Country:US
Practice Address - Phone:509-667-2027
Practice Address - Fax:509-663-8990
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020242225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist