Provider Demographics
NPI:1962782094
Name:EVANS, NICOLE MARIE (LMP)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:EVANS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA60239028
Mailing Address - Street 1:7401 CANYON RD E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-4906
Mailing Address - Country:US
Mailing Address - Phone:360-840-9444
Mailing Address - Fax:
Practice Address - Street 1:18801 VETERANS MEMORIAL DR E
Practice Address - Street 2:SUITE 5
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-5204
Practice Address - Country:US
Practice Address - Phone:360-840-9444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-20
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60239028225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist