Provider Demographics
NPI:1770077265
Name:WILLERT, AMANDA MARIE (LMT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:WILLERT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:DENKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4425 ISSAQUAH PINE LAKE RD SE APT Q6
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98075-6221
Mailing Address - Country:US
Mailing Address - Phone:612-220-0806
Mailing Address - Fax:
Practice Address - Street 1:1760 NEWPORT WAY NW
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5354
Practice Address - Country:US
Practice Address - Phone:425-998-6542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60867966225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist