Provider Demographics
NPI:1902137581
Name:PRINCE, MISTY (LMP)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:
Last Name:PRINCE
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 1:402 W WASHINGTON AVE STE E
Mailing Address - Street 2:
Mailing Address - City:UNION GAP
Mailing Address - State:WA
Mailing Address - Zip Code:98903-1440
Mailing Address - Country:US
Mailing Address - Phone:509-453-7368
Mailing Address - Fax:
Practice Address - Street 1:610 N ILER ST
Practice Address - Street 2:
Practice Address - City:MOXEE
Practice Address - State:WA
Practice Address - Zip Code:98936-9025
Practice Address - Country:US
Practice Address - Phone:509-949-5664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60077387225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist