Provider Demographics
NPI:1063466555
Name:FENTRESS, KASSANDRA (LMP)
Entity Type:Individual
Prefix:MISS
First Name:KASSANDRA
Middle Name:
Last Name:FENTRESS
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:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531
Mailing Address - Country:US
Mailing Address - Phone:360-740-5388
Mailing Address - Fax:360-740-3772
Practice Address - Street 1:1570 N NATIONAL AVE SUITE 204
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532
Practice Address - Country:US
Practice Address - Phone:360-740-5388
Practice Address - Fax:360-740-3772
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA20522225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist