Provider Demographics
NPI:1699980912
Name:VANCE, PENNY LEE
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:LEE
Last Name:VANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:LEE
Other - Last Name:VANCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:1430 W CASINO RD APT 53
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-7968
Mailing Address - Country:US
Mailing Address - Phone:425-267-0694
Mailing Address - Fax:
Practice Address - Street 1:20611 BOTHELL EVERETT HWY
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98012-7146
Practice Address - Country:US
Practice Address - Phone:425-487-0487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023588225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0219208OtherWORKERS COMP.