Provider Demographics
NPI:1548330327
Name:AGNEW, DIANE LYNN (LMP)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:LYNN
Last Name:AGNEW
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 1:6603 220TH ST SW STE 1
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-2186
Mailing Address - Country:US
Mailing Address - Phone:425-776-1056
Mailing Address - Fax:
Practice Address - Street 1:6603 220TH ST SW STE 1
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2186
Practice Address - Country:US
Practice Address - Phone:425-776-1056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00019886225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist