Provider Demographics
NPI:1396421657
Name:WISE, MONETTE JOSEPHINE (LMT)
Entity type:Individual
Prefix:
First Name:MONETTE
Middle Name:JOSEPHINE
Last Name:WISE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24309 165TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-9185
Mailing Address - Country:US
Mailing Address - Phone:206-571-6124
Mailing Address - Fax:
Practice Address - Street 1:24309 165TH AVE SE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-9185
Practice Address - Country:US
Practice Address - Phone:206-571-6124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60311937225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist