Provider Demographics
NPI:1053566208
Name:MILLIGAN, DEIRDRE KIM (MASSAGE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:KIM
Last Name:MILLIGAN
Suffix:
Gender:F
Credentials:MASSAGE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-8304
Mailing Address - Country:US
Mailing Address - Phone:360-808-1920
Mailing Address - Fax:
Practice Address - Street 1:660 EVERGREEN WAY
Practice Address - Street 2:AVALON MASSAGE & DAY SPA
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382
Practice Address - Country:US
Practice Address - Phone:360-582-9977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021540171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0218884OtherDEPARTMENT OF LABOR & INDUSTIRES