Provider Demographics
NPI:1538346101
Name:FALCONER, ELLEN (LMP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:FALCONER
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 1:441 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368-5739
Mailing Address - Country:US
Mailing Address - Phone:360-821-9368
Mailing Address - Fax:360-385-6044
Practice Address - Street 1:441 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-5739
Practice Address - Country:US
Practice Address - Phone:360-821-9368
Practice Address - Fax:360-385-6044
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-26
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00022097225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00022097OtherSTATE OF WASHINGTON
WAMA00022097OtherSTATE OF WASHINGTON