Provider Demographics
NPI:1053759373
Name:LUNDBERG, ALYSHA
Entity type:Individual
Prefix:
First Name:ALYSHA
Middle Name:
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20902 W INDIANA LN
Mailing Address - Street 2:
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-9681
Mailing Address - Country:US
Mailing Address - Phone:360-536-1719
Mailing Address - Fax:
Practice Address - Street 1:20902 W INDIANA LN
Practice Address - Street 2:
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022-9681
Practice Address - Country:US
Practice Address - Phone:360-536-1719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-08
Last Update Date:2013-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60229657225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist