Provider Demographics
NPI:1043994569
Name:MACKIE, KRISTEN LEE (DPT)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEE
Last Name:MACKIE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 S MERIDIAN STE 120
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-1654
Mailing Address - Country:US
Mailing Address - Phone:253-445-2733
Mailing Address - Fax:
Practice Address - Street 1:2930 S MERIDIAN STE 120
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-1654
Practice Address - Country:US
Practice Address - Phone:253-445-2733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61443440225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist