Provider Demographics
NPI:1003117482
Name:TAYLOR, KRISTIN (LMP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:TAYLOR
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 1:34400 NE TAYLOR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:LA CENTER
Mailing Address - State:WA
Mailing Address - Zip Code:98629-3408
Mailing Address - Country:US
Mailing Address - Phone:360-798-3105
Mailing Address - Fax:
Practice Address - Street 1:8507 S 5TH ST STE 104
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-3422
Practice Address - Country:US
Practice Address - Phone:360-798-3105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-16
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60188254225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist