Provider Demographics
NPI:1285754648
Name:KNUDTSON, MANDY ELLEN (LMP)
Entity type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:ELLEN
Last Name:KNUDTSON
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 1:10332 8TH PL SE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-9403
Mailing Address - Country:US
Mailing Address - Phone:425-673-7476
Mailing Address - Fax:
Practice Address - Street 1:7907 212TH ST SW
Practice Address - Street 2:SUITE 101A
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7541
Practice Address - Country:US
Practice Address - Phone:425-673-7476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA024201MA00014029225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist