Provider Demographics
NPI:1316289374
Name:XAYSANASONGKHAM, DAVINA (LMP)
Entity type:Individual
Prefix:
First Name:DAVINA
Middle Name:
Last Name:XAYSANASONGKHAM
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 1:10615 SE 250TH PL
Mailing Address - Street 2:C101
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-6497
Mailing Address - Country:US
Mailing Address - Phone:206-423-5776
Mailing Address - Fax:
Practice Address - Street 1:10615 SE 250TH PL
Practice Address - Street 2:C101
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-6497
Practice Address - Country:US
Practice Address - Phone:206-423-5776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-17
Last Update Date:2013-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60303913175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60303913OtherMASSAGE LICENSE NUMBER