Provider Demographics
NPI:1912988924
Name:MINNIS, CHARMAINE R (PT)
Entity type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:R
Last Name:MINNIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6
Mailing Address - Street 2:
Mailing Address - City:CHELAN
Mailing Address - State:WA
Mailing Address - Zip Code:98816-0006
Mailing Address - Country:US
Mailing Address - Phone:509-682-4713
Mailing Address - Fax:509-682-3218
Practice Address - Street 1:123 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:CHELAN
Practice Address - State:WA
Practice Address - Zip Code:98816
Practice Address - Country:US
Practice Address - Phone:509-682-4713
Practice Address - Fax:509-682-3218
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025208 PT00006114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8335622Medicaid
WA161721OtherPERSONAL L&I ID
WAGAB33831Medicare ID - Type UnspecifiedPERSONAL MEDICARE ID