Provider Demographics
NPI:1053591388
Name:NETTLES, TAWNYA RENE (LMP)
Entity type:Individual
Prefix:
First Name:TAWNYA
Middle Name:RENE
Last Name:NETTLES
Suffix:
Gender:F
Credentials:LMP
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 1101
Mailing Address - Street 2:675 ELWELL AVE
Mailing Address - City:DARRINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98241-1101
Mailing Address - Country:US
Mailing Address - Phone:425-231-4605
Mailing Address - Fax:
Practice Address - Street 1:4323 RUCKER AVE
Practice Address - Street 2:STE A
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2213
Practice Address - Country:US
Practice Address - Phone:425-231-4605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-03
Last Update Date:2007-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021904225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist