Provider Demographics
NPI:1528435500
Name:DURAN, ICYLE YVONNE (MA60591538)
Entity type:Individual
Prefix:
First Name:ICYLE
Middle Name:YVONNE
Last Name:DURAN
Suffix:
Gender:F
Credentials:MA60591538
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6053 21ST AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98106-1419
Mailing Address - Country:US
Mailing Address - Phone:206-948-0352
Mailing Address - Fax:
Practice Address - Street 1:5236 CALIFORNIA AVE SW STE D
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98136-1283
Practice Address - Country:US
Practice Address - Phone:206-331-3999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60591538225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist