Basic Information
| Provider Information | |||||||||
| NPI: | 1942617386 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENNACCHI | ||||||||
| FirstName: | NICHOLAS | ||||||||
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| NamePrefix: | MR. | ||||||||
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| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15811 AMBAUM BLVD SW | ||||||||
| Address2: | STE 110 | ||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981663066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062428211 | ||||||||
| FaxNumber: | 2062420162 | ||||||||
| Practice Location | |||||||||
| Address1: | 15811 AMBAUM BLVD SW | ||||||||
| Address2: | STE 110 | ||||||||
| City: | BURIEN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981663066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062428211 | ||||||||
| FaxNumber: | 2062420162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2014 | ||||||||
| LastUpdateDate: | 07/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA00014630 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.