Provider Demographics
NPI:1053550764
Name:RIDDELL, RENA JEANEEN (LMP)
Entity type:Individual
Prefix:MISS
First Name:RENA
Middle Name:JEANEEN
Last Name:RIDDELL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:MISS
Other - First Name:RENA
Other - Middle Name:J
Other - Last Name:RIDDELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:2501 SE MILE HILL DR
Mailing Address - Street 2:STE. A-101
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3500
Mailing Address - Country:US
Mailing Address - Phone:360-540-1751
Mailing Address - Fax:360-895-4210
Practice Address - Street 1:3061 SE MAPLE ST
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2945
Practice Address - Country:US
Practice Address - Phone:360-540-1751
Practice Address - Fax:360-895-4210
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-19
Last Update Date:2010-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAM60041452225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist