Provider Demographics
NPI:1861568883
Name:BIRDSTONE, SUNNY WALLIS (LMP)
Entity type:Individual
Prefix:MS
First Name:SUNNY
Middle Name:WALLIS
Last Name:BIRDSTONE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 S 77TH ST
Mailing Address - Street 2:LOT 8
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-5061
Mailing Address - Country:US
Mailing Address - Phone:253-473-3400
Mailing Address - Fax:253-476-1530
Practice Address - Street 1:821 HARVEY RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-4225
Practice Address - Country:US
Practice Address - Phone:253-833-1833
Practice Address - Fax:253-833-4642
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA9942225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0007372197OtherAETNA
WA218248218247OtherPREMERA BLUE CROSS
WA5316WAOtherREGENCE BLUE SHIELD
WA0137636OtherWA LABOR AND INDUSTRIES