Provider Demographics
NPI:1699269175
Name:WAYNE, ANTOINETTE EVONNE (LMP)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:EVONNE
Last Name:WAYNE
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 1:24630 WASHINGTON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6177
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:1804 W UNION AVE STE 101
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:951-696-9353
Practice Address - Fax:951-973-7216
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA60848027OtherMMT LICENSURE
WA1699269175OtherNPI